Monitoring of quality of care for atrial fibrillation after guideline introduction in Cyprus

Issue

Atrial fibrillation (AF) is a major contributor to morbidity and mortality in the elderly, and its effective management can reduce the associated health burden. However, real-world evidence shows persistent gaps in relevant guidelines’ implementation in Europe and elsewhere. In 2023, Cyprus contextualised the NICE NG196 AF guideline within its national health system and introduced measurable quality-of-care indicators.

Description of the problem

We evaluated guideline implementation through four indicators using national electronic health records across three periods: baseline (2022–2023) and two post-implementation years (2023–2025). Indicators captured key management domains: anticoagulation, screening, patient safety monitoring, and stroke risk stratification.

Results

The proportion of AF patients admitted for stroke on anticoagulation increased from 61.1% at baseline to 69.3% in year one (+8.2%, p = 0.086), with no further improvement in year two. More interestingly, pulse rhythm assessment in high-risk individuals improved markedly from 17.1% to 39.4% (+22.3%, p < 0.001) and further to 51.4% in year two (+12%, p < 0.001). In contrast, safety monitoring in anticoagulated patients was suboptimal at baseline and year one (67.8%) and declined to 58.6% in year two (−9.2%, p < 0.001), while stroke risk stratification using the CHA₂DS₂-VASc score was very limited, at 1.2% after implementation.

Lessons

Improvements were observed in anticoagulation and screening, but critical gaps remain in safety monitoring and risk stratification. Our findings highlight the need for stronger, system-level implementation, including decision support tools, incentives and integration of key practices into routine workflows.

Key messages

• Atrial Fibrillation guideline implementation in Cyprus improved screening and anticoagulation but revealed major gaps in patient safety monitoring and risk stratification.

• System-level and indicator-based monitoring can strengthen quality of care and reduce cardiovascular burden.