The primary objective is to determine whether a telemedicine-supported, village doctor-led integrated management model, AF-HF comorbidity ABC pathway and enhanced patient education, improves clinical outcomes compared with usual care among rural residents aged 65-80 years with AF and HF. The trial will evaluate whether integrated management reduces the MAGGIC HF risk score at 12 months (phase 1) and whether it reduces a composite cardiovascular endpoint, including cardiovascular death, ischemic or hemorrhagic stroke, hospitalization for worsening heart failure or acute coronary syndrome, and emergency visits due to atrial fibrillation over 36 months (phase 2). An extended observational follow-up, the composite cardiovascular endpoint observational follow-up study, will be conducted at Year 6 to evaluate long-term effects.
The village clinics need to be willing and able to provide integrated care to their patients with atrial fibrillation; 2. The village doctors from one village clinic serves all AF patients from 3-5 nearby villages; 3. The village doctors are trained to have a fundamental understanding of telemedicine; 4. Patients are eligible for participation if 1)they aged 65-80 years. 2) Electrocardiogram (ECG) confirmation of AF or possession of a diagnostic certificate for AF issued by a specialist. 3) A documented history of HF, or newly diagnosed HF according to the 2026 ESC Guidelines for the management of heart failure. HF will require current or prior typical symptoms and/or signs attributable to a structural and/or functional cardiac abnormality. Participants with LVEF <50% will be classified as having heart failure with reduced ejection fraction (HFrEF). In participants with LVEF ≥50%, heart failure with preserved ejection fraction (HFpEF) will require objective evidence of cardiac structural and/or functional abnormalities consistent with left ventricular diastolic dysfunction or elevated filling pressures, supported by elevated natriuretic peptide levels. In participants with AF, supportive echocardiographic abnormalities will include left atrial volume index (LAVI) >40 mL/m², E/e' >15, pulmonary artery systolic pressure >35 mmHg, or tricuspid regurgitation velocity >2.8 m/s. 4) Management by a village clinic near the participant's place of residence. 5) Ability to understand the study procedures and provide written informed consent.
Expected life expectancy of less than 12 months.
Severe renal insufficiency (Ccr < 30ml/min) or ongoing dialysis treatment.
Cardiac insufficiency secondary to correctable causes, including hyperthyroid heart disease, anemic heart disease, or uncorrected congenital heart disease.
Indications for pacemaker implantation without having undergone implantation.
Parallel
Village-Doctor Led Integrated Care
Other intervention1. Village doctor-led management: At least one follow-up visit per month will be conducted either at the village clinic or in the patient's home, including assessment of clinical status, monitoring of vital signs, medication review, risk screening, and health education. 2. Telemedicine specialist support: When symptoms fluctuate, treatment adjustment is difficult or a management problem arises, the village doctor may upload symptoms, ECG recordings, blood pressure, heart rate and examination materials through a dedicated telemedicine platform. 3. Standardised guideline training. Village doctors will receive tiered training based on the AF-HF comorbidity ABC pathway. 4. Patient education: Participants will receive the study team's 18 core AF-HF self-management messages through monthly face-to-face education, regular short-message reminders and illustrated brochures, reinforcing medication adherence, symptom monitoring, salt and fluid restriction, exercise rehabilitation.
Usual Care
Other interventionUsual care includes routine follow-up, general health education, medication registration, and standard referral procedures provided by local primary care providers. Participants will not receive the structured village-doctor led integrated care program.
Primary Outcome of Phase 1: Change in MAGGIC Heart Failure Risk Score
A heart failure prognostic model integrating 13 key predictors, including age, LVEF, systolic blood pressure, BMI, serum creatinine, NYHA functional class, and medication status.
Primary Outcome of Phase 2: Composite Cardiovascular Endpoint
Composite cardiovascular endpoint, including cardiovascular death, ischemic or hemorrhagic stroke, hospitalization for worsening heart failure or acute coronary syndrome, and emergency visits due to atrial fibrillation.
Primary Outcome of Extension Study: Composite cardiovascular endpoint
Composite cardiovascular endpoint, including cardiovascular death, ischemic or hemorrhagic stroke, hospitalization for worsening heart failure or acute coronary syndrome, and emergency visits due to atrial fibrillation.
Cardiovascular Death
Cardiovascular death was defined as death attributable to myocardial infarction, heart failure, arrhythmia, cardiac perforation or tamponade, or other deaths of cardiac origin. Death caused by ischemic stroke, hemorrhagic stroke, peripheral embolism, and pulmonary embolism was also classified as cardiovascular death
Cardiovascular Hospitalization
Hospitalization due to cardiovascular or neurological diseases at township-level or higher hospitals, including heart failure, cardiac arrhythmia, acute coronary syndrome, hypertensive emergency or urgency, ischemic or hemorrhagic stroke, and transient ischemic attack.
Emergency Visit for Cardiovascular Events
Incidence of emergency visits for cardiovascular events, including exacerbation of heart failure or acute coronary syndrome.
ischemic or hemorrhagic Stroke
All strokes: ischemic or hemorrhagic Stroke
Click on the lead sponsor to view all of their trials.
Jiangsu Taizhou People's Hospital
Lead sponsor
The First Affiliated Hospital with Nanjing Medical University
Collaborator
