Epidemiología de la fibrilación auricular en España en los últimos 20 años

Real-world data in primary care: validation of diagnosis of atrial fibrillation in primary care electronic medical records and estimated prevalence among consulting patients'

BACKGROUND

Primary care electronic medical records contain clinical-administrative information on a high percentage of the population. Before this information can be used for epidemiological purposes, its quality must be verified. This study aims to validate diagnoses of atrial fibrillation (AF) recorded in primary care electronic medical records and to estimate the prevalence of AF in the population attending primary care consultations.

METHODS

We performed a cross-sectional validation study of all diagnoses of AF recorded in primary care electronic medical records in Madrid (Spain). We also performed simple random sampling of diagnoses of AF (ICPC-2 code K78) registered by 55 physicians and random age- and sex-matched sampling of the records that included a diagnosis of AF. Electrocardiograms, echocardiograms, and hospital discharge or cardiology clinic reports were matched. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and overall agreement were calculated using the kappa statistic (κ). The prevalence of AF in the community of Madrid was estimated considering the sensitivity and specificity obtained in the validation. All calculations were performed overall and by sex and age groups.

RESULTS

The degree of agreement was very high (κ = 0.952), with a sensitivity of 97.84%, specificity of 97.39%, PPV of 97.37%, and NPV of 97.85%. The prevalence of AF in the population aged over 18 years was 2.41% (95%CI 2.39-2.42% [2.25% in women and 2.58% in men]). This increased progressively with age, reaching 16.95% in those over 80 years of age (15.5% in women and 19.44% in men).

CONCLUSIONS

The validation results obtained enable diagnosis of AF recorded in primary care to be used as a tool for epidemiological studies. A high prevalence of AF was found, especially in older patients.

Oral Anticoagulant Use and Appropriateness in Elderly Patients with Atrial Fibrillation in Complex Clinical Conditions: ACONVENIENCE Study

Non-valvular atrial fibrillation (NVAF) is the most common arrhythmia in older patients. Although direct-acting oral anticoagulants (DOAC) are the antithrombotic treatment of choice, irrespective of age, certain factors may limit their use. The aim of the ACONVENIENCE study was to consult the opinion of a multidisciplinary panel of experts on the appropriateness of using OACs in elderly patients (>75 years) with NVAF associated with certain complex clinical conditions. A consensus project was performed on the basis of a systematic review of the literature, and application of a two-round Delphi survey. The agreement of 79 panellists on 30 Delphi-type statements was evaluated, and their opinion on the appropriateness of different oral anticoagulants in 16 complex clinical scenarios was assessed. A total of 27 consensus statements were agreed upon, including all statements addressing anticoagulation in older patients and in patients at high risk of bleeding complications, and most of those addressing frailty, dementia, risk of falling, and complex cardiac situations. It was almost unanimously agreed upon that advanced age should not influence the anticoagulation decision. Apixaban was the highest-rated therapeutic option in 14/16 situations, followed by edoxaban. There is a high degree of agreement on anticoagulation in older patients with NVAF. Age should not be the single limiting factor when prescribing OACs, and the decision should be made based on net clinical benefit and a comprehensive geriatric assessment. Apixaban, followed by edoxaban, was considered the most appropriate treatment in the various complex clinical situations examined.

Mortality risk factors in patients with SARS-CoV-2 infection and atrial fibrillation: Data from the SEMI-COVID-19 registry

INTRODUCTION

Atrial fibrillation and associated comorbidities pose a risk factor for mortality, morbidity and development of complications in patients admitted for COVID-19.

OBJECTIVES

To describe the clinical, epidemiological, radiological and analytical characteristics of patients with atrial fibrillation admitted for COVID-19 in Spain. Secondarily, we aim to identify those variables associated with mortality and poor prognosis of COVID-19 in patients with atrial fibrillation.

METHODS

Retrospective, observational, multicenter, nationwide, retrospective study of patients hospitalized for COVID-19 from March 1 to October 1, 2020. Data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine (SEMI) in which 150 Spanish hospitals participate.

RESULTS

Between March 1 and October 1, 2020, data from a total of 16,461 patients were entered into the SEMI-COVID-19 registry. 1816 (11%) had a history of atrial fibrillation and the number of deaths among AF patients amounted to 738 (41%). Regarding clinical characteristics, deceased patients were admitted with a higher heart rate (88.38 vs. 84.95; P>0.01), with a higher percentage of respiratory failure (67.2 vs. 20.1%; P<0.01) and high tachypnea (58 vs. 30%; P<0.01). The comorbidities that presented statistically significant differences in the deceased group were: age, hypertension and diabetes with target organ involvement. There was also a higher prevalence of a history of cardiovascular disease in the deceased. On multivariate analysis, DOACs treatment had a protective role for mortality (OR: 0.597; CI: 0.402-0.888; P=0.011).

CONCLUSIONS

Previous treatment with DOACs and DOACs treatment during admission seem to have a protective role in patients with atrial fibrillation, although this fact should be verified in prospective studies.

Mortality risk factors in patients with SARS-CoV-2 infection and atrial fibrillation: Data from the SEMI-COVID-19 registry

Introduction

Atrial fibrillation and associated comorbidities pose a risk factor for mortality, morbidity and development of complications in patients admitted for COVID-19.

Objectives

To describe the clinical, epidemiological, radiological and analytical characteristics of patients with AF admitted for COVID-19 in Spain. Secondarily, we aim to identify those variables associated with mortality and poor prognosis of COVID-19 in patients with AF.

Methods

Retrospective, observational, multicenter, nationwide, retrospective study of patients hospitalized for COVID-19 from March 1 to October 1, 2020. Data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine (SEMI) in which 150 Spanish hospitals participate.

Results

Between March 1 and October 1, 2020, data from a total of 16,461 patients were entered into the SEMI-COVID-19 registry. 1,816 (11%) had a history of AF and the number of deaths among AF patients amounted to 738 (41%). Regarding clinical characteristics, deceased patients were admitted with a higher heart rate (88.38 vs 84.95; p > 0.01), with a higher percentage of respiratory failure (67.2% vs 20.1%; p < 0.01) and high tachypnea (58% vs 30%; p < 0.01). The comorbidities that presented statistically significant differences in the deceased group were: age, hypertension and diabetes with target organ involvement. There was also a higher prevalence of a history of cardiovascular disease in the deceased. On multivariate analysis, DOACs treatment had a protective role for mortality (OR:0,597) IC (0,402-0,888 ; p = 0.011).

Conclusions

Previous treatment with DOACs and DOACs treatment during admission seem to have a protective role in patients with AF, although this fact should be verified in prospective studies.

Detection of hidden atrial fibrillation in primary care using a long-term band-based ECG registration system: The DESCUUBRE-FA study

OBJECTIVE

To assess whether the use of a band-based electrocardiographic (ECG) monitoring system improves the diagnostic accuracy of traditional diagnostic methods for the detection of atrial fibrillation (AF).

METHODS

Multicenter and observational study of primary care patients at risk of AF. To be included, patients had to be aged ≥70 years, with no known AF, and have at least 1 major criterion (obesity, hyperthyroidism, heart failure) or 2 minor criteria (hypertension, diabetes, female sex, ischemic stroke, transient ischemic attack or systemic embolism, COPD, dyslipidemia, ischemic heart disease, peripheral artery disease). All patients were monitored using the Nuubo™ system for a single 2-week period.

RESULTS

A total of 600 patients were included (median age 77 years; 70% women; 84.3% hypertension, 27.2% diabetes, 9.2% prior stroke). The global rate of diagnosis of new AF in the overall population was 2.83%. All patients with AF were anticoagulated. In numerical terms, patients with AF (vs no AF) had a higher number of supraventricular extrasystoles and episodes of supraventricular tachycardia, as well as longer P wave duration; however, these differences did not reach statistical significance. Overall, participants were very satisfied with the device, and no relevant limitations in daily activities were observed during the 2-week study period.

CONCLUSIONS

In an elderly population at risk of AF, a band-based ECG monitoring approach applied for only 2 weeks detected approximately 3% of new cases of AF, leading to a change in antithrombotic therapy. Most participants considered the device easy to use and comfortable.

Genetic and Metabolic Determinants of Atrial Fibrillation in a General Population Sample: The CHRIS Study

Atrial fibrillation (AF) is a supraventricular arrhythmia deriving from uncoordinated electrical activation with considerable associated morbidity and mortality. To expand the limited understanding of AF biological mechanisms, we performed two screenings, investigating the genetic and metabolic determinants of AF in the Cooperative Health Research in South Tyrol study. We found 110 AF cases out of 10,509 general population individuals. A genome-wide association scan (GWAS) identified two novel loci (p-value < 5 × 10-8) around SNPs rs745582874, next to gene PBX1, and rs768476991, within gene PCCA, with genotype calling confirmed by Sanger sequencing. Risk alleles at both SNPs were enriched in a family detected through familial aggregation analysis of the phenotype, and both rare alleles co-segregated with AF. The metabolic screening of 175 metabolites, in a subset of individuals, revealed a 41% lower concentration of lysophosphatidylcholine lysoPC a C20:3 in AF cases compared to controls (p-adj = 0.005). The genetic findings, combined with previous evidence, indicate that the two identified GWAS loci may be considered novel genetic rare determinants for AF. Considering additionally the association of lysoPC a C20:3 with AF by metabolic screening, our results demonstrate the valuable contribution of the combined genomic and metabolomic approach in studying AF in large-scale population studies.

Changing paradigms: from prevention of thromboembolic events to improved survival in patients with atrial fibrillation

Atrial fibrillation is associated with a five-fold increase in the risk of stroke. Current guidelines recommend the use of the CHA2DS2-VASc score to stratify the risk of stroke. In addition, guidelines recommend the identification of the conditions that increase the risk of haemorrhage to be modified and thus decrease the risk of bleeding. Nevertheless, many patients with a high thromboembolic risk are prescribed antiplatelet treatment or do not receive any antithrombotic therapy. In addition, therapeutic inertia is common in anticoagulated patients taking vitamin K antagonists, and underdosing is an emerging problem with direct oral anticoagulants, probably because many physicians consider the risk of stroke and the risk of major bleeding to be equal. It is necessary to develop a new approach to risk stratification, an approach that moves from morbidity to mortality, i.e., from stratification of the risk of stroke and major bleeding to stratification of the risk of mortality associated with stroke and the risk of mortality associated with bleeding. In this article, we propose a novel risk stratification approach based on the mortality associated with stroke and bleeding, illustrated by data derived from the literature.

Economic evaluation of an ultra-high density mapping system compared to non-ultra-high density mapping systems for radiofrequency catheter ablation procedures in patients with atrial fibrillation

PURPOSE

Advanced non-fluoroscopic mapping systems for radiofrequency ablation (RFA) have shown to be an effective treatment of atrial fibrillation. This study analyzes the resource usage and subsequent costs associated with the implementation of an ultra-high density mapping system (UHDMS) compared to non-ultra-high density mapping systems (NUHDMS).

METHODS

This retrospective observational study included 120 patients (18 years or older) with paroxysmal or persistent atrial fibrillation who underwent RFA for de novo pulmonary vein isolation guided either by an UHDMS (n=63) or NUHDMS (n=57) for their index procedure. We compared patient characteristics, short- and long-term procedural outcomes, resource usage, and clinical outcomes followed up to 16 months between the two treatment groups. The cost analysis was conducted from the perspective of a single center in Spain (Clinica Universidad de Navarra).

RESULTS

Neither baseline patient characteristics nor complication rate differed between groups. Repeat RFAs following recurrent arrhythmia at 16 months was lower in the UHDMS patient group than in the NUHDMS group (6 vs. 14, respectively; P=0.027). The average total cost per patient was €1,600 lower in the UHDMS group, compared to the NUHDMS group (€11,061 and €12,661, respectively; P=0.03).

CONCLUSION

In patients treated with an NUHDMS, 25% had a repeat ablation for recurrent arrhythmia, whereas only 9% of patients treated with a UHDMS had one (61% relative risk reduction), resulting in an average cost saving per patient of €1,600.

Analysis of the Association Between Electrocardiographic P-wave Characteristics and Atrial Fibrillation in the REGICOR Study

INTRODUCTION AND OBJECTIVES

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia. P-wave duration and interatrial blocks (IAB) have been reported to be associated with AF. Our aim was to determine the individual and combined association of P-wave duration and advanced IAB morphology with AF.

METHODS

We designed an age-, sex-, and survey-matched case-control study nested in a population-based cohort (REGICOR: REgistre GIroní del COR). Two different surveys recruited a total of 9380 participants from 1999 to 2005; all participants were invited to a second examination between 2009 and 2013. For the present study, we selected participants aged 25 to 79 years with follow-up through the end of the study. All electrocardiograms were analyzed by 2 observers to determine P-wave duration and morphology (normal, partial, or advanced IAB).

RESULTS

The median follow-up was 7.12 years. Eighty participants presented with AF, had a legible baseline electrocardiogram, and were included in the study, along with 160 controls. P-wave duration and the presence of partial or advanced IAB were associated with AF. When P-wave duration and morphology were considered together, only P-wave duration (≥ 110 milliseconds) showed an independent and strong association with AF. The odds ratio for AF of P-wave duration between 110-119, 120-129 and ≥ 130 milliseconds vs < 110 milliseconds were 5.33; 95%CI, 1.74-16.33, 5.08; 95%CI, 1.73-14.90 and 5.44; 95%CI, 1.95-15.15, respectively.

CONCLUSIONS

A P-wave longer than 110 milliseconds increases the risk of AF. Advanced IAB morphology did not seem to provide an additional AF risk beyond that of P-wave duration.

[Therapeutic equivalence of the new oral anticoagulants]

In an attempt to minimize the economic impact due to the incorporation of innovative drugs, health authorities have promoted and supported the evaluation and market positioning of drugs, as equivalent therapeutic alternatives. This issue has recently gained importance, possibly due to the current economic crisis. The equivalent therapeutic alternatives are justified by the need to compete on price, and by the authorities recommendation to establish therapeutic equivalence, price and financing of medicinal products at the same time. The establishment of the new oral anticoagulants and the equivalent therapeutic alternatives is a problematic issue if it is based on the absence of direct comparisons between different drugs and the questionable methodology used in the current indirect comparisons. Currently, it is difficult to determine when a new oral anticoagulant is more recommendable than others, but efforts are being made in order to propose alternatives for the decision based on patient characteristics.

Update in cardiac arrhythmias and pacing

This article discusses the main advances in cardiac arrhythmias and pacing published between 2013 and 2014. Special attention is given to the interventional treatment of atrial fibrillation and ventricular arrhythmias, and on advances in cardiac pacing and implantable cardioverter defibrillators, with particular reference to the elderly patient.

Association between rs2200733 and rs7193343 genetic variants and atrial fibrillation in a Spanish population, and meta-analysis of previous studies

INTRODUCTION AND OBJECTIVES

The objectives of this study were to analyze the association between two genetic variants (rs2200733 and rs7193343) in a Spanish population and the risk of developing atrial fibrillation, and to carry out a systematic review and meta-analysis of these associations.

METHODS

We performed a case-control study involving 257 case patients with atrial fibrillation and 379 controls. The case patients were individuals who had donated samples to the Spanish National DNA Bank; the controls were participating in a population-based cross-sectional study. Genotyping was carried out using a TaqMan assay. We conducted a systematic literature search in which 2 independent reviewers extracted the necessary information. The study involved a meta-analysis, a heterogeneity analysis, and a meta-regression analysis to identify the variables that explain the heterogeneity across studies.

RESULTS

In our population, the presence of atrial fibrillation was found to be associated with rs2200733 (odds ratio = 1.87; 95% confidence interval, 1.30-2.70), but not with rs7193343 (odds ratio = 1.18; 95% confidence interval, 0.80-1.73). In the meta-analysis, we observed an association between atrial fibrillation and both variants: odds ratio = 1.71 (95% confidence interval, 1.54-1.90) for rs2200733 and odds ratio = 1.18 (95% confidence interval, 1.11-1.25) for rs7193343. We observed heterogeneity among the studies dealing with the association between rs2200733 and atrial fibrillation, partially related to the study design, and the strength of association was greater in case-control studies (odds ratio = 1.83) than in cohort studies (odds ratio = 1.41).

CONCLUSIONS

Variants rs2200733 and rs7193343 are associated with a higher risk of atrial fibrillation. Case-control studies tend to overestimate the strength of association between these genetic variants and atrial fibrillation.

Short- and long-term prognosis of previous and new-onset atrial fibrillation in ST-segment elevation acute myocardial infarction

INTRODUCTION AND OBJECTIVES

The impact of atrial fibrillation on the prognosis of myocardial infarction is still the subject of debate. We analyzed the influence of previous and new-onset atrial fibrillation on in-hospital and long-term prognosis in patients with acute myocardial infarction.

METHODS

Prospective study of 4284 patients with ST-segment elevation acute myocardial infarction. We studied all-cause in-hospital and long-term mortality (median, 7.2 years) using adjusted models.

RESULTS

In total, 3.2% of patients had previous atrial fibrillation and 9.8% had new-onset atrial fibrillation. In general, both groups of patients had a high baseline risk profile and an increased likelihood of in-hospital complications. The crude in-hospital mortality rate was higher in patients with previous atrial fibrillation than in those with new-onset atrial fibrillation (22% vs 12%; P<.001; 30% vs 10%; P<.001). The long-term mortality rate was 11.11/100 patient-years in patients with previous atrial fibrillation and 5.35/100 patient years in those with new-onset atrial fibrillation (both groups, P<.001). New-onset fibrillation alone (odds ratio=1.55; 95% confidence interval, 1.08-2.22) was an independent predictor of in-hospital mortality. Previous atrial fibrillation (hazard ratio=1.24; 95% confidence interval, 0.94-1.64) and new-onset atrial fibrillation (hazard ratio=0.98; 95% confidence interval, 0.80-1.21) were not independent predictors of long-term mortality.

CONCLUSIONS

New-onset atrial fibrillation during hospitalization is an independent risk factor for in-hospital mortality in acute myocardial infarction.