Prevalence, clinical correlates and treatment of permanent atrial fibrillation among the elderly: insights from the first prospective population-based study in rural Greece

Review of screening studies for atrial fibrillation in rural populations of 11 countries

Atrial fibrillation (AF) is a common cardiac arrhythmia, and pathological burden can be influenced by environmental factors. The rural environment may influence the burden of AF, although no systematic review studies have been conducted to address this issue. We performed a systematic review of AF screening studies conducted in rural global populations to determine the burden, risk factors, and screening methods surrounding AF in these settings. Out of the 1792 articles gathered from a keyword search of medical databases and reference lists, 18 publications from 11 countries were included in our analysis. The pooled prevalence of AF across the studies was 2.05% (95% confidence interval, 1.97%-2.13%) and ranged from 0.3% to 10.87%. Only one study utilized a handheld electrocardiogram to screen AF, while the rest used the 12-lead electrocardiogram. AF risk factors reported across studies varied and included increasing age, male gender, hypertension, diabetes, prior myocardial infarction or stroke, obesity, hyperlipidemia/hypercholesterolemia, alcohol consumption, and heart failure. However, none of the studies assessed all risk factors. We suggest that future research on AF in rural communities examine a complete checklist of AF risk factors to better understand their influence on AF burden and development. This will aid in understanding rural prevention strategies and the management of detected AF cases specific to rural areas. At present, the burden of AF in rural communities is poorly understood and has been underreported.

Treatment pathways for patients with atrial fibrillation

BACKGROUND

Although there has been growing concordance over what constitutes best practice in recent guidelines for treatment of atrial fibrillation (AF), notably regarding anticoagulant use, it remains unclear whether patients are being treated accordingly.

AIMS

The aims of this study were to explore the pattern of treatment pathways - i.e. how patients are treated over time - for patients with AF, and to test the hypothesis that comparative to patients in lower stroke-risk categories (as measured by CHADS(2) score), patients with higher CHADS(2) scores are less likely to discontinue anticoagulant therapy or, if not started on anticoagulant treatment, more likely to be transferred to anticoagulant therapy, in keeping with guideline recommendations.

SETTING

A total of 67,857 patients with a diagnosis of AF in practices registered with the General Practice Research Database.

METHODS

A series of possible treatment pathways were identified, and for each initial treatment, we estimated the probability of treatment change and the average time that a patient newly diagnosed with AF spent on a particular treatment, projected across 5 years and stratified by CHADS(2) score.

RESULTS

There was no relationship between CHADS(2) score and maintenance or discontinuation of particular approaches to antithrombotic treatment. While those beginning on antiplatelet therapy were more likely to change treatment than those on anticoagulants (approximately 60% vs. 50% within the first year), as much as one-third of treatment time of all those starting on a therapeutic approach involving anticoagulants featured no use of anticoagulants (either as monotherapy or in combination) over the 5-year period, and whether treatment was discontinued or maintained did not vary by CHADS(2) score. No difference was found in treatment pathways controlling for post-2002 diagnoses as against the whole sample.

CONCLUSIONS

Although there is more evidence of treatment maintenance than treatment change, especially in the first year after diagnosis, the amount of therapeutic change remains noteworthy and appears higher than in some previous studies. Prescription patterns for AF therapy suggest that too few high-risk patients are receiving best practice treatment, and particularly of concern is that some of these patients are being transferred away from best practice treatment over time.