Effect of telemedicine-based integrated management of atrial fibrillation in village clinics on recurrent nonfatal cardiovascular events: a secondary analysis of the MIRACLE-AF trial

BACKGROUND: Atrial fibrillation (AF) is an increasing public health challenge, particularly among rural older adults, where awareness and treatment remain inadequate. While the MIRACLE-AF trial demonstrated that telemedicine-based, village doctor-led integrated care reduced cardiovascular mortality or first major cardiovascular events, its impact on recurrent nonfatal cardiovascular events remains unknown. OBJECTIVE: To evaluate the effect of the MIRACLE-AF care model on recurrent nonfatal cardiovascular events. METHODS: We conducted a secondary analysis of the MIRACLE-AF trial (NCT04622514), a cluster-randomized controlled trial enrolling 1,039 rural patients aged ≥65 years with confirmed AF across 30 village clinics over 36 months. Village clinics were randomized 1:1 to village doctor-led telemedicine integrated care or enhanced usual care. The primary outcome was recurrent nonfatal events over 36 months, including strokes, hospitalizations for worsening heart failure or acute coronary syndrome, and emergency visits for AF, analyzed using a conditional frailty model. RESULTS: Among 1039 patients (mean age 75.8 ± 5.7 years; 44.3% female), the intervention experienced fewer cardiovascular events than the control (118 events in 82 patients [15.65%] vs. 173 events in 122 patients [23.69%]). The observed recurrent event rates were 6.75 and 9.11 per 100 patient-years, respectively. The estimated hazard ratio was 0.76 (95% CI, 0.583-1.004; p = 0.053), indicating that the difference did not reach statistical significance. CONCLUSION: Although the overall difference did not reach statistical significance, directional trends consistently favored telemedicine-based integrated care, suggesting a potential reduction in recurrent cardiovascular event burden. Larger studies with longer follow-up are needed to confirm these findings.