Table 3.

Roadblocks, strategies, and potential solutions.

Dimension	Roadblock	Strategy	Potential solutions
Geographic accessibility	Long distances to clinics result in low numbers of rural patients presenting to clinics for screening and follow-up appointments.	Improve accessibility of screening for rural populations. Strengthen capacity for ECG testing in remote areas. Promote the use of digital technology to improve screening and diagnosis of AF.	Train community health workers or pharmacists to screen for possible AF with pulse-checking in non-clinic settings. Educate in schools about checking pulse and relationship of AF with stroke. Educate at-risk populations (e.g., those 65+ years of age) to self-screen with pulse checks. Implement novel telemedicine technologies (e.g., transmission of ECG results from rural areas to urban facilities) including handheld digital rhythm strips (accepted by ESC for AF diagnosis). Use digital technology or ‘wearables’ to conduct non-invasive screening (e.g., PPG readings generated from smartphones, though ECG still required for diagnosis). Use digital technology for remote patient follow up (e.g., phone or video calls).
Availability	Shortage of health care professionals with training in AF, including interpretation of ECG, initiation of and monitoring of anticoagulation therapy. Absence of rhythm-control strategies Lack of integration of AF management services with other cardiology and medical care.	Raise awareness of AF among health care professionals. Reduce dependence on highly trained medical staff for AF screening and management. Implement coherent rhythm control strategies. Better integration with other cardiology and medical services.	Conduct awareness campaigns through healthcare professional networks. Improve postgraduate training and CME. Develop simple and locally applicable AF guidelines. Implement non-physician healthcare workers (NPHW)-managed anticoagulation program. Increase governmental funding. Progress towards Universal Health Coverage (UHC). Train human resources. Set up AF research and registries in LMICs to ascertain the disease patterns specific to these countries. Involve allied health professionals for monitoring and follow-up purposes. Rely on electronic solutions (e.g., smartphones and apps) to provide patients with regular guidance. Promote awareness of AF management in related medical services (hypertension, heart failure, coronary artery disease, medical). Treat and prevent contributory factors (e.g., hypertension, heart failure, coronary artery disease).
Affordability	OACs potentially unaffordable for patient households, resulting in nonadherence to treatment regime. Pharmaceutical poverty. Access to non-pharmacological rhythm control strategies, i.e., catheter ablation, LAAO.	Improve affordability of OACs and other essential medicines so that every patient can access them. Design novel treatment environments such as office-based labs.	Provide universal health care coverage for essential medicines, or provide similar support via a not-for-profit organisation). Implement internationally recognized policies for the reduction of essential medicine costs. Ensure that national essential medicines lists include NOACs. Promote the availability of NOACs as generics. Office-based labs provide safe and affordable spaces for interventions in AF patients.
Acceptability	Reluctance of physicians and patients to initiate anticoagulation therapy. Lack of awareness of importance of persistent adherence to OAC therapy.	Improve awareness of and capacity for managing OAC. therapy among physicians. Improve patient understanding of importance of OAC therapy and capacity to adhere to therapy.	Conduct country-specific training on OAC therapy management and support programmes for non-cardiologist health care professionals with the support of professional patient organisations when available. Develop and implement country-specific patient education, health literacy, and support programmes for diagnosed AF patients on OAC therapy and foster the dissemination of existing resources across countries. Support the development of structured patient organisations. Foster patient-centred approaches to support medication adherence and effective lifestyle risk reduction. Foster patient self-management and adherence to medication through digital technology and connected devices. Conduct research into feasibility of self-monitoring programmes for patients on OAC therapy in LMICs.
Quality	Unavailability of standards or norms to ascertain the quality of certain new devices, services, and treatments. Lack of patient-reported outcomes. Lack of a clear definition of quality indicators and markers, including specificities per regions.	Implement robust mechanisms for the accreditation/certification of new devices, services, and treatments. Rely on a set of standardised patient report outcomes. Adopt a globally acceptable definition of quality indicators and markers.	Create a list of certified devices, apps, etc. Ensure that technology is supported by a clear pathway to treatment. Foster implementation research. Promote the use of a standard set of patient-reported outcomes among health practitioners (195). Use a common definition of quality indicators and markers.