Telemedicine-based Integrated Management of Atrial Fibrillation and Heart Failure in Older Patients in Village Clinics

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and mutually reinforce one another, forming a "vicious cycle" that is particularly destructive in older adults. Older patients with AF are at high risk for HF progression, and AF-HF comorbidity is a central determinant of long-term prognosis. In rural China, effective prevention and long-term management face practical bottlenecks, including inadequate early HF screening and insufficient intensity of targeted prevention. Previous studies suggest that "process-oriented" integration alone, such as the standard ABC pathway, may be insufficient for rural AF patients in whom HF risk is dominant. To address these gaps, the MIRACLE-AF II study aims to establish a village doctor-led model that integrates guideline-directed medical therapy (GDMT) with multidimensional lifestyle interventions, supported by telemedicine and intelligent decision assistance. By integrating early HF screening, medication access, and a scalable lifestyle intervention (including peer-group cardiac rehabilitation, behavioral education, and smart wearable device monitoring) into a tele-supported workflow, this project seeks to effectively improve clinical outcomes for older patients. This is a cluster-randomized controlled trial conducted in rural areas of Jiangsu Province, China. Village clinics are randomized in a 1:1 ratio to either a digital intelligent integrated management group (intervention) or a conventional management group (control). The study enrolls permanent residents aged 65 to 80 years with confirmed AF and a documented history or screening-based diagnosis of HF. The trial is divided into two phases: a 12-month follow-up to compare the HF prognosis score (MAGGIC score) between the two groups, and a 36-month follow-up to compare composite endpoint events, including cardiovascular death, ischemic or hemorrhagic stroke, hospitalization due to worsening HF or acute coronary syndrome (ACS), and emergency visits for AF.