Key result
Village doctor-led integrated telemedicine cuts major CV events ~37% vs usual care in multimorbid AF.
Why the study?
Multimorbidity is common and linked to worse outcomes in older patients with AF, and the impact of telemedicine-based, village doctor-led integrated care in this subgroup was uncertain.
Does a telemedicine-based, village doctor-led integrated care model reduce composite cardiovascular and AF-related adverse outcomes compared to usual care in older patients with atrial fibrillation and multimorbidity in rural China?
RCT (n=586)
Cluster-randomised (1:1)
Yes
Does a telemedicine-based, village doctor-led integrated care model reduce composite cardiovascular and AF-related adverse outcomes compared to usual care in older patients with atrial fibrillation and multimorbidity in rural China?
In older patients with atrial fibrillation and multimorbidity in rural China, a telemedicine-based, village doctor-led integrated care model significantly reduced composite cardiovascular events and heart failure/ACS hospitalizations compared to usual care.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The magnitude of the reduction in serious cardiovascular events in patients in the intervention group is impressive. Our results indicate that the telemedicine-based, village doctor-led, AF specialist-supported intervention was effective and is a feasible and sustainable implementation strategy that could be scaled-up to improve the management of atrial fibrillation in the older population across rural China and in other low-and-middle income countries with limited health-care access.”
“This study demonstrates the effectiveness of a telemedicine-based, village doctor-led approach in bridging the gap in AF management in rural China. By leveraging technology and local healthcare providers, we can ensure that even the most underserved populations receive high-quality, evidence-based care.”
“Elderly patients with AF in rural China are difficult to reach due to their low educational level, limited access to information technology, long travel time to hospitals, and travel difficulties. The only way we can reach them is to empower village doctors to provide good quality chronic disease care.”
Supports telemedicine-integrated care for older multimorbid AF patients in rural settings; extends MIRACLE-AF benefits to this high-risk subgroup.
Background The MIRACLE-AF (a Novel Model of Integrated Care of Older Patients with Atrial Fibrillation in Rural China) cluster-randomised trialdemonstrated that a telemedicine-based, village doctor-led integrated care model significantly reduced the risk of a composite cardiovascular outcome among older patients with atrial fibrillation (AF) in rural China. Multimorbidity is highly prevalent in older patients with AF and is associated with worse clinical outcomes but the impact of telemedicine-based, village doctor-led integrated care on patients with multimorbidity is uncertain. Purpose To evaluate whether the MIRACLE-AF integrated care intervention reduced adverse clinical events in patients with multimorbidity. Methods This post-hoc subgroup analysis included patients with multimorbidity from the MIRACLE-AF trial. Multimorbidity was defined as the presence of ≥2 comorbid conditions, including hypertension, hyperlipidemia, diabetes, coronary artery disease, heart failure, cardiomyopathy, peripheral arterial disease, prior stroke or systemic embolism, or liver or kidney dysfunction. In the MIRACLE-AF trial, 30 village clinics (clusters) were randomly assigned (1:1) to the intervention group (telemedicine-based, village doctor-led integrated care) or the control group (usual care). The primary outcome was a composite of cardiovascular death, all strokes, hospitalisation due to worsening heart failure or acute coronary syndrome (ACS), and emergency visits due to AF. Secondary outcomes included the individual components of the primary composite, all-cause mortality, major bleeding, and clinically relevant non-major bleeding. Cox proportional hazard models were used to estimate treatment effects, adjusting for cluster effects and baseline risk factors. Results Among the 1,039 patients in the primary analysis of the MIRACLE-AF trial (mean age 75.8 ± 5.7 years; 44.3% women), 586 patients with multimorbidity were analysed, including 301 in the intervention group and 285 in the control group. Over a median follow-up of 34 months, the annualised rate of the primary composite outcome was significantly lower in the intervention group than in the control group (7.1% vs. 12.0% per year; rate difference -4.88 percentage points, 95% CI -7.45 to -2.31,P<0.001; adjusted HR 0.63, 95% CI 0.48 to 0.83, P<0.001). Hospitalisation due to worsening heart failure or ACS was significantly reduced with the intervention (3.3% vs. 5.8% per year; rate difference -2.51% percentage points, 95% CI -4.76% to 0.26%, P = 0.0301; adjusted HR 0.62, 95% CI 0.40 to 0.96, P=0.030). Other secondary outcome did not differ significantly between groups. Conclusions In patients with AF and multimorbidity, the telemedicine-based, village doctor-led MIRACLE-AF integrated care intervention was associated with a significant reduction in the composite primary outcome, when compared with usual care.
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Li et al. (2026) conducted an RCT in Atrial fibrillation with multimorbidity (n=586). Telemedicine-based, village doctor-led integrated care vs. Usual care was evaluated on Composite of cardiovascular death, all strokes, hospitalisation due to worsening heart failure or acute coronary syndrome (ACS), and emergency visits due to AF (HR 0.63, 95% CI 0.48-0.83, p=<0.001). Telemedicine-based, village doctor-led integrated care reduced the primary composite cardiovascular outcome vs usual care in multimorbid AF patients (7.1% vs 12.0%/yr; HR 0.63, 95% CI 0.48-0.83).
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