JAMA Netw Open. 2026 Mar 2;9(3):e261385. doi: 10.1001/jamanetworkopen.2026.1385.
ABSTRACT
IMPORTANCE: Delivering integrated atrial fibrillation (AF) care to rural patients remains challenging. Patients aged 75 years and older in rural areas represent a particularly at-risk subgroup, and effective and scalable strategies to optimize AF care in this population are urgently needed.
OBJECTIVE: To evaluate the effectiveness of a village doctor-led, telemedicine-supported integrated care model in rural patients aged 75 years and older with AF.
DESIGN, SETTING, AND PARTICIPANTS: This was a prespecified subgroup analysis of the Novel Model of Integrated Care of Older Patients With Atrial Fibrillation in Rural China (MIRACLE-AF) cluster randomized clinical trial, which was conducted across 30 village clinics in Jiangdu County, Jiangsu Province, China, from December 2020 to May 2024. Patients with AF aged 65 years and older and residing in rural villages under study were eligible for the MIRACLE-AF trial. In this prespecified subgroup study, patients aged 75 years and older were analyzed. Additional age cutoffs (≥70, ≥75, and ≥80 years) were applied to assess the consistency of intervention benefits across age groups.
INTERVENTIONS: Village doctor-led, telemedicine-supported integrated AF care or usual care.
MAIN OUTCOMES AND MEASURES: A composite of cardiovascular death, ischemic or hemorrhagic stroke, hospitalization for worsening heart failure or acute coronary syndrome, and emergency visits for AF.
RESULTS: Among 1039 patients included in the primary analysis of the MIRACLE-AF trial (mean [SD] age, 75.8 [5.7] years; 460 women [44.3%]), 589 patients with AF aged 75 years or older (median [IQR] age, 79 [77-82] years; 273 women [46.3%]) were included in this analysis. Among them, 297 patients received the MIRACLE-AF intervention and 292 patients received usual care. Over 36 months of follow-up, the MIRACLE-AF intervention resulted in a significantly lower risk of the primary composite outcome compared with usual care (7.4%; 95% CI, 5.6%-9.2% vs 11.3%; 95% CI, 8.5%-14.1% per year; rate difference, -3.93 percentage points; 95% CI, -7.41 to -0.44 percentage points; P = .02; adjusted hazard ratio, 0.70; 95% CI, 0.49 to 0.98; P = .04).
CONCLUSIONS AND RELEVANCE: In this prespecified subgroup analysis of the MIRACLE-AF trial, a novel care model significantly improved outcomes in patients with AF aged 75 years or older in rural settings.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04622514.
PMID:41817526 | DOI:10.1001/jamanetworkopen.2026.1385