Nurse-led vs. usual-care for atrial fibrillation

E. P. J. Petra Wijtvliet, Robert G. Tieleman, Isabelle C. van Gelder, Nikki A. H. A. Pluymaekers, Michiel Rienstra, Richard J. Folkeringa, Patrick Bronzwaer, Arif Elvan, Jan Elders, Raymond Tukkie, Justin G. L. M. Luermans, A. D. I. Thea Van Asselt, Sander M. J. Van Kuijk, Jan G. Tijssen, Harry J. G. M. Crijns*, RACE 4 Investigators

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Background Nurse-led integrated care is expected to improve outcome of patients with atrial fibrillation compared with usual-care provided by a medical specialist.

Methods and results We randomized 1375 patients with atrial fibrillation (6410 years, 44% women, 57% had CHA(2)DS(2)-VASc >= 2) to receive nurse-led care or usual-care. Nurse-led care was provided by specialized nurses using a decision-support tool, in consultation with the cardiologist. The primary endpoint was a composite of cardiovascular death and cardiovascular hospital admissions. Of 671 nurse-led care patients, 543 (81%) received anticoagulation in full accordance with the guidelines against 559 of 683 (82%) usual-care patients. The cumulative adherence to guidelines-based recommendations was 61% under nurse-led care and 26% under usual-care. Over 37months of follow-up, the primary endpoint occurred in 164 of 671 patients (9.7% per year) under nurse-led care and in 192 of 683 patients (11.6% per year) under usual-care [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.69 to 1.04, P=0.12]. There were 124 vs. 161 hospitalizations for arrhythmia events (7.0% and 9.4% per year), and 14 vs. 22 for heart failure (0.7% and 1.1% per year), respectively. Results were not consistent in a pre-specified subgroup analysis by centre experience, with a HR of 0.52 (95% CI 0.37-to 0.71) in four experienced centres and of 1.24 (95% CI 0.94-1.63) in four less experienced centres (P for interaction

Conclusion Our trial failed to show that nurse-led care was superior to usual-care. The data suggest that nurse-led care by an experienced team could be clinically beneficial ( NCT01740037).

Original languageEnglish
Pages (from-to)634-641
Number of pages8
JournalEuropean Heart Journal
Issue number5
Publication statusPublished - 1 Feb 2020


  • Atrial fibrillation
  • Cardiovascular mortality and morbidity
  • Nurse-led care
  • Stroke
  • Heart failure
  • Usual-care
  • Randomized clinical trial
  • RISK

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