Real World Data for Value Improvement in Atrial Fibrillation Care

Atrial fibrillation (AF) is the most common cardiac arrhythmia and contributes significantly to patient morbidity, reduced quality of life, and increased healthcare consumption. As the prevalence of AF continues to rise, care strategies must evolve to ensure they reflect not only rhythm control goals but also outcomes that matter to patients. This thesis investigates how real-world data can be applied to optimise AF care pathways, with a focus on both symptomatic and transient forms of AF. The thesis is structured in two parts. Part I addresses the optimisation of catheter ablation in patients with symptomatic AF. This treatment has become central to rhythm control, yet considerable variation persists in procedural practice, follow-up, and outcome evaluation.Chapter 2 compares pulsed field ablation with cryoballoon ablation in routine clinical practice. The analysis highlights how new technologies differ in procedure duration and workflow efficiency, potentially offering broader system-level benefits beyond clinical efficacy alone.The influence of patient-reported outcomes is addressed in Chapter 3, which examines whether pre-procedural quality of life predicts the likelihood of redo ablation. Patients with lower baseline scores were more likely to undergo repeat procedures, suggesting that PROMs can help guide treatment evaluation and shared decision-making.Care pathway organisation is considered in Chapter 4, which evaluates same-day discharge following pulmonary vein isolation. The findings demonstrate that, in appropriate candidates, this approach is both safe and resource-efficient, supporting a more streamlined and patient-centred model of care.Patterns of healthcare utilisation prior to ablation are explored in Chapter 5. The analysis identifies a subgroup of patients with high care consumption before their procedure. These patients may benefit from proactive monitoring, targeted counselling, and earlier rhythm interventions to reduce repeat procedures and improve outcomes.In Chapter 6, a cost-consequence analysis compares different ablation strategies, linking procedural choices to both clinical and economic outcomes. The findings offer insights relevant to value-based healthcare, supporting informed decision-making for patients, clinicians, and health systems.Part II extends the value-based approach to transient and secondary forms of AF. While catheter ablation in symptomatic AF has been the subject of growing optimisation efforts, care for postoperative and hospital-acquired AF remains less standardised. These conditions are frequently managed using tools developed for chronic AF, despite differences in underlying mechanism, duration, and recurrence risk.Evidence for oral anticoagulation after coronary artery bypass grafting in patients with postoperative AF is synthesised in Chapter 7. The meta-analysis questions routine continuation of anticoagulation beyond the early postoperative phase, given the modest thromboembolic benefit and elevated bleeding risk. Chapter 8 uses national registry data to examine real-world anticoagulation patterns after POAF. The study finds substantial variation in prescribing and frequent non-adherence to guidelines, highlighting the need for more consistent and evidence-based decision-making.The question of whether aspirin adds value when used alongside oral anticoagulation is addressed in Chapter 9. Among patients with a baseline indication for OAC, no benefit was observed in terms of graft patency, while bleeding risk was significantly increased. These findings support a move towards selective monotherapy in post-CABG patients.Thromboembolic risk associated with AF during non-cardiac hospitalisations is examined in Chapter 10. The results show that not all episodes confer long-term risk, suggesting that anticoagulation should not be continued in the absence of documented recurrence.Together, the findings presented in this thesis highlight key opportunities to personalise AF care, reduce overtreatment, and improve the identification of patients at increased risk of poor outcomes. Rather than relying on static decision tools, the results support a shift towards dynamic and evidence-informed risk stratification. Real-world data play a central role in enabling this approach, offering the granularity and contextual relevance needed to guide more adaptive and patient-centred care.In conclusion, this thesis demonstrates how real-world data can be used to improve atrial fibrillation care across a range of clinical scenarios. In symptomatic AF, success should be assessed not only by rhythm outcomes but also by improvements in quality of life and healthcare efficiency. In transient AF, particularly POAF, long-term treatment decisions should be guided by recurrence monitoring and net clinical benefit rather than extrapolated guideline frameworks.The studies presented here support a broader definition of value in AF care, incorporating patient-reported outcomes, healthcare utilisation, and individualised treatment strategies. As AF continues to grow in prevalence and complexity, these insights offer direction for more effective, sustainable, and patient-centred care pathways.