Integrated management of atrial fibrillation and comorbidities in the community: a generalist-specialist collaborative RCT and subgroup analysis

Objective To develop, implement, and evaluate a community-based, patient-centered integrated care model for atrial fibrillation (AF) characterized by generalist-specialist collaboration and cardio-cerebrovascular co-management, and to examine whether its effectiveness varies across key patient subgroups. Methods A prospective, single-blind, randomized controlled trial was conducted. Between June 2024 and May 2025, 160 patients with AF were consecutively enrolled from the Shanghai Weifang Community Health Service Center and Renji Hospital, affiliated to Shanghai Jiao Tong University, School of Medicine. Participants were randomly assigned to either a control group or an intervention group, with 80 patients in each. The intervention group received comprehensive management based on a collaborative framework between general practitioners (GPs) and specialists. The control group received routine community-based chronic disease management and follow-up. After a 12-month intervention period, outcomes were compared between the two groups, including the attainment rates for body mass index (BMI), blood pressure, and blood glucose control; levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP); left ventricular ejection fraction (LVEF); standardized anticoagulation and heart rate control medication use; and the primary composite endpoint (heart failure or stroke). Subgroup analyses were prespecified for age (<75 vs. ≥75 years), sex, and CHA 2 DS 2 -VASc score (2–3 vs. ≥4). Interaction P values were derived from logistic regression models including treatment-by-subgroup product terms. Results A total of 150 patients completed the 12-month follow-up, with 75 patients in each group. The intervention group demonstrated significantly higher attainment rates for BMI, blood pressure, and blood glucose control compared to the control group. Regarding cardiac function, LVEF showed significant improvement in the intervention group, whereas no significant difference was observed in NT-proBNP levels between the groups. Furthermore, the standardized usage rates for both anticoagulant and heart rate control medications were significantly higher in the intervention group. For primary endpoint events, the incidence of the composite outcome (heart failure or stroke) was significantly lower in the intervention group. Subgroup analyses revealed no significant interactions for age ( P = 0.82), sex ( P = 0.75), or CHA 2 DS 2 -VASc score ( P = 0.18), indicating consistent intervention effects across these strata. Conclusion The generalist-specialist collaborative integrated care model effectively improves risk factor control, cardiac function, and treatment standardization, and reduces major adverse cardiovascular events in community-dwelling AF patients. The benefits are consistent across age, sex, and comorbidity burden subgroups, supporting its broad applicability in primary care settings.