Integrated care pathway

The current healthcare approach to multimorbidity is fragmented. AFFIRMO aims to move from fragmentation to an integrated pathway designed to be Patient-centred, Systemic and Digital


AFFIRMO's care pathway will account of personal preferences for treatment and considers the social context of patients. The treatment strategy will be the result of a shared decision-making process.


AFFIRMO's care pathway will enable synergies and cooperation among the different health disciplines involved in the treatment of patients with multimorbidity.


AFFIRMO's care pathway will rely on a digital platform, based on open standards, developed to assist physicians in applying and tailoring a personalised care strategy.

The workplan

AFFIRMO’s integrated care pathway will focus on Atrial Fibrillation (AF), a cardiac arrhythmia associated with high risk of morbidity. The workplan is structured around three research areas:

Clusters of multimorbidity

Researchers will characterize how different patterns of multimorbidity are distributed within the population of older individuals with AF.

Combining multiple analysis techniques, the team will investigate the reciprocal relationships between the most common diseases and AF. Drug patterns and potential drug reactions will also be addressed.

Stakeholder involvement

The project will assess the needs of patients, caregivers, and health professionals for the comprehensive management of multimorbidity (including AF) and examines ways of optimizing care and self-management.

Data will be collected though surveys and interviews. The goal is to develop a set of quality performance indicators (QPIs) to support the co-designing process of the care approach proposed by AFFIRMO.

Integrated care pathway

AFFIRMO will develop, implement and test patient-cantered approach on older multimorbid AF patients in the clinical practice. The proposed approach will rely on a digital platform designed to bring patients, caregivers, and health professionals closer together through information sharing.

An international clinic study will be performed to assess the effectiveness of the AFFIRMO’s care approach. Researchers will also consider the economic dimension by identifying how the integrated pathway will impact health outcomes and costs.


A multidisciplinary consortium across Europe representing clinical research, epidemiology, data science, biostatistics, pharmacology, economics, psychology and social sciences.

European Journal of Internal Medicine 123 (2024) 37–41

Detection of subclinical atrial fibrillation with cardiac implanted electronic devices: What decision making on anticoagulation after the NOAH and ARTESiA trials?

Boriani, Giuseppe Gerra, Luigi Mei, Davide A Bonini, Niccolo Vitolo, Marco Proietti, Marco Imberti, Jacopo F

Atrial fibrillation (AF) may be asymptomatic and the extensive monitoring capabilities of cardiac implantable electronic devices (CIEDs) revealed asymptomatic atrial tachi-arrhythmias of short duration (minutes-hours) occurring in patients with no prior history of AF and without AF detection at a conventional surface ECG. Both the terms “AHRE” (Atrial High-Rate Episodes) and subclinical AF were used in a series of prior studies, that evidenced the association with an increased risk of stroke. Two randomized controlled studies were planned in order to assess the risk-benefit profile of anticoagulation in patients with AHRE/subclinical AF: the NOAH and ARTESiA trials. The results of these two trials (6548 patients enrolled, overall) show that the risk of stroke/systemic embolism associated with AHRE/subclinical AF is in the range of 1–1.2 % per patient-year, but with an important proportion of severe/fatal strokes occurring in non-anticoagulated patients. The apparent discordance between ARTESiA and NOAH results may be approached by considering the related study-level meta-analysis, which highlights a consistent reduction of ischemic stroke with oral anticoagulants vs. aspirin/placebo (relative risk [RR] 0.68, 95 % CI 0.50–0.92). Oral anticoagulation was found to increase major bleeding (RR 1.62, 95 % CI 1.05–2.5), but no difference was found in fatal bleeding (RR 0.79, 95 % CI 0.37–1.69). Additionally, no difference was found in cardiovascular death or all-cause mortality. Taking into account these results, clinical decision-making for patients with AHRE/subclinical AF at risk of stroke, according to CHA2DS2-VASc, can now be evidence-based, considering the benefits and related risks of oral anticoagulants, to be shared with appropriately informed patients.

VALUE HEALTH. 2024; 27(4):527–541

The Cost of Atrial Fibrillation: A Systematic Review

Buja, Alessandra Rebba, Vincenzo Montecchio, Laura Renzo, Giulia Baldo, Vincenzo Cocchio, Silvia Ferri, Nicola Migliore, Federico Zorzi, Alessandro Collins, Brendan Amrouch, Cheima De Smedt, Delphine Kypridemos, Christodoulos Petrovic, Mirko O'Flaherty, Martin Lip, Gregory Y.H.


Atrial fibrillation (AF) is the most common cardiac arrhythmia, with an increasing incidence and prevalence because of progressively aging populations. Costs related to AF are both direct and indirect. This systematic review aims to identify the main cost drivers of the illness, assess the potential economic impact resulting from changes in care strategies, and propose interventions where they are most needed.


A systematic literature search of the PubMed and Scopus databases was performed to identify analytical observational studies defining the cost of illness in cases of AF. The search strategy was based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 recommendations.


Of the 944 articles retrieved, 24 met the inclusion criteria. These studies were conducted in several countries. All studies calculated the direct medical costs, whereas 8 of 24 studies assessed indirect costs. The median annual direct medical cost per patient, considering all studies, was €9409 (13 333 US dollars in purchasing power parities), with a very large variability due to the heterogeneity of different analyses. Hospitalization costs are generally the main cost drivers. Comorbidities and complications, such as stroke, considerably increase the average annual direct medical cost of AF.


In most of the analyzed studies, inpatient care cost represents the main component of the mean direct medical cost per patient. Stroke and heart failure are responsible for a large share of the total costs; therefore, implementing guidelines to manage comorbidities in AF is a necessary step to improve health and mitigate healthcare costs.