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has considerable variability over time, affecting its contribution to the AF-promoting substrate. The risk profile of each patient is also far from static, and requires a dynamic mode of care to ensure optimal AF management.710,711 Patients with AF require periodic reassessment of therapy based on this changing risk status if we are to improve the overall quality of care. Timely attention to modifiable factors and underpinning comorbidities has the potential to slow or reverse the progression of AF, increase quality of life, and prevent adverse outcomes such as heart failure, thromboembolism, and major bleeding. The [E] in AF-CARE encompasses the range of activity needed by healthcare professionals and patients to: (i) thoroughly evaluate associated comorbidities and risk factors that can guide treatment; and (ii) provide the dynamic assessment needed to ensure that treatment plans remain suited to that particular patient. This task force recommends an adaptive strategy that not only reacts to changes notified by a patient, but also proactively seeks out issues where altering management could impact on patient wellbeing. Avoidance of unnecessary and costly follow-up is also inherent in this framework, with educated and empowered patients contributing to identifying the need for access to specialist care or an escalation of management. The patient-centred, shared decision philosophy is embedded to improve efficiency in models of care and to address the needs of patients with AF. Medical history and the results of any tests should be regularly reevaluated to address the dynamic nature of comorbidities and risk factors.712 This may have impact on therapeutic decisions; e.g. resumption of full-dose DOAC therapy after improvement in the patient’s renal function. The timing of review of the AF-CARE pathway is patient specific and should respond to changes in clinical status. In most cases, this task force advises re-evaluation 6 months after initial presentation, and then at least annually by a healthcare professional in primary or secondary care (see Figure 3).

8.1 Implementation of dynamic care

A multidisciplinary-based approach is advocated to improve implementation of dynamic AF-CARE (see Figure 2); although potentially resource intensive, this is preferred to more simplistic or opportunistic methods. For example, in a pragmatic trial of 47 333 AF patients identified through health insurance claims, there was no difference in OAC initiation at 1 year in those randomized to a single mailout of patient and clinician education, compared with those in the usual care group.713 For co-ordination of care there is a core role for cardiologists, general practitioners, specialized nurses, and pharmacists.714 If needed, and depending on local resources, others may also be involved (cardiac surgeons, physiotherapists, neurologists, psychologists, and other allied health professionals). It is strongly advocated that one core team member coordinates care, and that additional team members become involved according to the needs of the individual patient throughout their AF trajectory. Several organizational models of integrated care for AF have been evaluated, but which components are most useful remains unclear. Some models include a multidisciplinary team,715,716 while others are nurse-led79,122,124,717 or cardiologist-led.79,122,124,717 Several published models used computerized decision support systems or electronic health applications.79,122,715,718 Evaluation within RCTs has demonstrated mixed results due to the variety of methods tested and differences in regional care. Several studies report significant improvements with respect to adherence to anticoagulation, cardiovascular mortality, and hospitalization relative to standard of care.121–123 However, the RACE 4 (IntegRAted Chronic Care Program at Specialized AF Clinic Versus Usual CarE in Patients with Atrial Fibrillation) trial, which included 1375 patients, failed to demonstrate superiority of nurse-led over usual care.79 New studies of the components and optimal models for delivery for integrated care approaches in routine practice are ongoing (ACTRN12616001109493, NCT03924739).

8.2 Improving treatment adherence

Advances in the care of patients with AF can only be effective if appropriate tools are available to support the implementation of the treatment regimen.719 A number of factors are related to the optimal implementation of care at the level of: (i) the individual patient (culture, cognitive impairment, and psychological status); (ii) the treatment (complexity, side effects, polypharmacy, impact on daily life, and cost); (iii) the healthcare system (access to treatment and multidisciplinary approach); and (iv) the healthcare professional (knowledge, awareness of guidelines, expertise, and communication skills). A collaborative approach to patient care, based upon shared decision-making and goals tailored to individual patient needs, is crucial in promoting ongoing patient adherence to the agreed treatment regimen.720 Even when treatment seems feasible for the individual, patients often lack access to reliable and up-to-date information about risks and benefits of various treatment options, and consequently are not empowered to engage in their own management. A sense of ownership that promotes the achievement of joint goals can be encouraged through the use of educational programmes, websites (such as https://afibmatters.org), app-based tools, and individually tailored treatment protocols which take into account gender, ethnic, socioeconomic, environmental, and work factors. In addition, practical tools (e.g. schedules, apps, brochures, reminders, pillboxes) can help to implement treatment in daily life.721,722 Regular review by members of the multidisciplinary team enables the evolution of a flexible and responsive management regimen that the patient will find easier to follow.

8.3 Cardiac imaging

A TTE is a valuable asset across all four AF-CARE domains when there are changes in the clinical status of an individual patient (Figure 13).723–725 The key findings to consider from an echocardiogram are any structural heart disease (e.g. valvular disease or left ventricular hypertrophy), impairment of left ventricular function (systolic and/or diastolic to classify heart failure subtype), left atrial dilatation, and right heart dysfunction.59,67,726 To counter irregularity when in AF, obtaining measurements in cardiac cycles that follow two similar RR intervals can improve the value of parameters compared with sequential averaging of cardiac cycles.723,727 Contrast TTE or alternative imaging modalities may be required where image quality is poor, and quantification of left ventricular systolic function is needed for decisions on rate or rhythm control. Other cardiac imaging techniques, such as cardiac magnetic resonance (CMR), CT, TOE, and nuclear imaging can be valuable when: (i) TTE quality is suboptimal for diagnostic purposes; (ii) additional information is needed on structure, substrate, or function; and (iii) to support decisions on interventional procedures (see Supplementary data online, Figure S1).59,724,725,728 As with TTE, other types of cardiac imaging can be challenging in the context of AF irregularity or with rapid heart rate, requiring technique-specific modifications when acquiring ECG-gated sequences.729–731 Downloaded from academic.oup.com/eurheartj/article/45/36/3314/7738779 by guest on 07 October 2026