An epidemiological study of symptomatic paroxysmal atrial fibrillation in northwest Greece

Management of patients with atrial fibrillation by primary-care physicians in Germany: 1-year results of the ATRIUM registry

BACKGROUND

Patients with atrial fibrillation (AF) in Germany are often managed jointly by primary-care physicians in cooperation with cardiologists. We aimed to investigate the management and 1-year outcomes of AF patients in this setting.

HYPOTHESIS

We set out to describe the current management of AF patients in primary care settings in Germany.

METHODS

Observational registry with 1-year follow-up, performed by a representative, randomly selected sample of 781 primary-care physicians in Germany.

RESULTS

Of 3781 patients with electrocardiographically documented AF, 3163 patients (age 71.9 ± 9.2 years, 57.9% males) were followed for 1 year; 28.4% had paroxysmal, 27.0% persistent, and 43.3% permanent AF. Comorbid conditions were common (mean CHA2 DS2-VASc score 3. 8 ± 1.7). Rhythm-control therapy was used in 16.4%. Although oral anticoagulation was often used (82.7% at baseline), stroke rate during follow-up was high (2.7% stroke, 3.0% transient ischemic attack). Despite a long duration of AF (mean duration 61 months at enrollment), 18.5% of patients were hospitalized during the 1-year follow-up.

CONCLUSIONS

In this unselected group of patients with long-standing AF managed in primary care, hospitalizations and cardiovascular complications including strokes are frequent, illustrating the need to improve management of AF patients.

Gender differences in patients with atrial fibrillation

AIMS

We aimed to compare gender differences with respect to presentation of consecutive ambulatory patients with atrial fibrillation (AF), management of their disease, and outcomes.

METHODS

Post-hoc analysis of an observational (non-interventional) study performed by 616 office- and hospital-based cardiologists in Germany. Consecutive (mainly ambulatory) patients with Electrocardiography (ECG) -confirmed AF and available data from baseline (BL) and two follow-up visits at 6 and 12 months were assessed.

RESULTS

A total of 2,742 patients (62.8% males, mean age 67.5 years; 37.2% women, mean age 71.2 years) were analysed. Women had more frequently paroxysmal and less frequently permanent AF. Quality of life scores were slightly worse in women compared to men, for all types of AF. For class III anti-arrhythmic drugs at baseline (more frequent in men), and for digitalis (less frequent in men at BL and 1 year) statistically significant differences were noted. Oral anti-coagulation (OAC) without anti-platelet drugs was given in 67.9% at BL and in 62.7% at 1 year (no differences between genders). During follow-up, drug conversions in men/women were reported in 12.3%/14.9% (p=0.054), and electrical conversions in 14.6%/11.7% (p=0.03). Hospitalisations occurred in 25.9% and strokes in 3.5%. Patients with higher CHA2DS2-VASc scores had increased stroke rates (0, 1 and ≥2 points: 0.0, 1.5 and 3.9%, respectively; with no significant gender differences).

CONCLUSION

In everyday management of patients with AF, there were no differences in treatment and major outcomes, in particular stroke, between women and men. This finding is opposed to earlier studies reporting OAC undertreatment of women and higher stroke rates.

Atrial fibrillation management, outcomes and predictors of stable disease in daily practice: prospective non-interventional study

BACKGROUND

We aimed to describe the current management of patients with atrial fibrillation (AF) by cardiologists, and to identify predicting factors for a stable disease course.

METHODS

2753 consecutive patients with ECG-confirmed AF in the previous 12 months were documented in a 1-year observational (non-interventional) study from 616 centers. Stable disease was defined as having neither AF related intervention nor change in antiarrhythmic therapy in the previous 12 months. Stepwise selection of parameters for multivariate regression was used to identify factors for stable AF.

RESULTS

At baseline, paroxysmal AF was reported in 33.5%, persistent in 26.7%, and permanent in 39.7%; rate control alone was the prevailing antiarrhythmic strategy (64.2%). Drugs for thromboembolic prevention were administered in 93.8%, with a clear predominance of oral anticoagulants (OAC), alone or in combination with antiplatelet drugs. Electrical or pharmacological conversions were reported in 23.6%. A total of 96 (3.5%) patients in the total cohort experienced stroke, 72 patients (2.6%) TIA, and 24 (0.9%) arterial embolism. 26% were hospitalized during follow-up (0.4 events per patient), and 9.4% developed incident heart failure (42% prevalence at follow-up). The rate of stable patients was 43.4%. In the multivariate model male gender, history of stroke, and permanent (vs. persistent) AF were associated with stable disease. Conversely, the factors chronic heart failure, impaired left ventricular function, rhythm-control (vs. other), OAC and antiplatelet therapy were significantly correlated with unstable disease.

CONCLUSIONS

The relatively low proportion of stable patients and in particular, the high hospitalization and stroke rate indicate difficulties in everyday management of patients with AF.

Management of atrial fibrillation by primary care physicians in Germany: baseline results of the ATRIUM registry

Background

In contrast to surveys in cardiologist settings, presentation and management of atrial fibrillation (AF) in primary care patients is less well studied.

Methods and results

The prospective ATRIUM (OutpatientRegistry Upon Morbidity of Atrial Fibrillation) collected data from patients with AF seen by 730 physicians representing a random sample of all primary care physicians in Germany. ATRIUM enrolled 3,667 patients (mean age, 72 ± 9 years; 58% male, mean CHADS₂ score 2.2 ± 1.3), 994 (27.1%) with paroxysmal, 944 (25.7%) with persistent or long-standing persistent and 1,525 (41.6%) with permanent AF (no AF type was specified in 204 patients). Mean duration since initial diagnosis of AF was 61 ± 66 months (median 42, interquartile range 14–88). Reported symptoms included palpitations (43%), shortness of breath (49%), fatigue (49%), dizziness (37%) and angina (20%). Most common concomitant conditions were hypertension (84%), heart failure (43%), coronary artery disease (345%), diabetes (35%) and chronic kidney disease (20%). Prior myocardial infarction was present in 11% of patients, prior stroke in 10% and prior transient ischemic attack in 10%. Antithrombotic medication was used by 93% of the patients (oral anticoagulants, 83%). Rate control therapy was reported in 75% and rhythm control therapy in 33%, often added to rate control. Drugs for rhythm and rate control included ß-blockers (75%), calcium antagonists (15%), digitalis (29%), sodium channel blockers of type IA (quinidine, 1.0%) or IC (flecainide or propafenone, 5%), and potassium channel blockers including amiodarone (11%). In the year prior to enrollment, 46% of the patients had been cardioverted (23% by drugs, 22% electrically), catheter ablation had been performed in 5%, and 10% received a pacemaker or defibrillator. A high proportion (44%) of the patients were hospitalized in the year prior to enrollment.

Conclusions

Patients with AF managed in primary care often receive guideline-conforming therapy including antithrombotic therapy, rate control and rhythm control (numbers given above). Despite this apparent adherence, almost half of the patients were hospitalized in the year prior to enrollment, suggesting that the therapies applied do not stabilize patients sufficiently to keep them out of hospital.

Presentation of atrial fibrillation and its management by cardiologists in the ambulatory and hospital setting: MOVE cross-sectional study

OBJECTIVE

The aim of the study was to collect comprehensive data on atrial fibrillation (AF) in ambulatory and hospital-based management in Germany.

METHODS

Consecutive patients with ECG-confirmed AF in the previous 12 months were documented in a non-interventional study in 638 physician offices (78.0%) or hospitals (12.7%).

RESULTS

Of the 3354 patients (mean age 68.9 ± 10.1 years; CHADS(2) score 1.9 ± 1.3), a total of 1136 (33.9%) had paroxysmal, 899 (26.8%) persistent, 1295 (38.6%) permanent and 24 (0.7%) unspecified AF. In the 12 months prior to documentation, pharmacological conversion was attempted in 18.2%, electric cardioversion in 17.5%, the combination of both in 31.2%, and catheter ablation of AF in 5.5%. Only 41.4% of patients met the definition of stable disease (having neither AF related intervention nor change in antiarrhythmic therapy in the previous 12 months). As treatment strategy, physicians stated rate control in 64%, rhythm control in 8%, and both in 19% (not reported: 8%). Patients received antiarrhythmic drugs of class IA in 1.3%, IC in 13.8%, II in 78.1%, III in 17.9%, IV in 9.7% and digitalis in 26.7%. Drugs for thromboembolic prevention (oral anticoagulants and/or antithrombotics) were administered in 81.5%. Hospitalisations for AF or associated diseases in the previous 12 months were reported in 34.2%. Possible limitations include the open, observational design, selection of physicians with particular interest in the field and selection of patients (i.e. underrepresentation of critically ill individuals).

CONCLUSIONS

While treatment rates with regards to the prevention of thromboembolic events were among the highest reported to date, the low proportion of stable patients and in particular, the high hospitalisation rate hint at difficulties in the management of patients with AF in clinical practice.

Atrial fibrillation management: a prospective survey in ESC Member Countries

AIMS

To describe atrial fibrillation (AF) management in member countries of the European Society of Cardiology (ESC) and to verify cardiology practices against guidelines.

METHODS AND RESULTS

Among 182 hospitals in 35 countries, 5333 ambulant and hospitalized AF patients were enrolled, in 2003 and 2004. AF was primary or secondary diagnosis, and was confirmed on ECG in the preceding 12 months. Clinical type of AF was reported to be first detected in 978, paroxysmal in 1517, persistent in 1167, and permanent in 1547 patients. Concomitant diseases were present in 90% of all patients, causing risk factors for stroke to be also highly prevalent (86%). As many as 69% of patients were symptomatic at the time of the survey; among asymptomatic patients, 54% were previously experienced symptoms. Oral anticoagulation was prescribed in 67 and 49% of eligible and ineligible patients, respectively. A rhythm control strategy was applied in 67% of currently symptomatic patients and in 44% of patients who never experienced symptoms.

CONCLUSION

This survey provides a unique snapshot of current AF management in ESC member countries. Discordance between guidelines and practice was found regarding several issues on stroke prevention and antiarrhythmic therapy.

Propafenone added to ibutilide increases conversion rates of persistent atrial fibrillation

OBJECTIVE

To assess the effectiveness and safety of pharmacological conversion of persistent atrial fibrillation (AF) with a combined propafenone plus ibutilide regimen.

METHODS AND RESULTS

100 consecutive patients (66 men, mean (SD) age 65 (10) years) with persistent AF (mean (SD) duration 99 (92) days) admitted for elective pharmacological cardioversion were randomly assigned to treatment with either intravenous ibutilide (1 mg plus an additional 1 mg, if required; n = 51) or oral propafenone (600 mg) plus intravenous ibutilide at the same dose (n = 49). Success rates were 41.1% (21 of 51 patients) for ibutilide alone and 71.4% (35 of 49 patients) for propafenone plus ibutilide (p = 0.0044). However, cardioversion occurred earlier in the ibutilide alone group (55 (20) minutes) compared with the combination group (81 (32) minutes, p = 0.0019). A comparable increase in the QTc interval was observed in both groups but one case of sustained torsade de pointes, requiring electrical cardioversion, was observed in the propafenone plus ibutilide group. No other complications were noted during the hospitalisation period.

CONCLUSION

Concurrent administration of propafenone plus ibutilide for pharmacological cardioversion of persistent AF is safe and more effective than ibutilide alone.

Errors and pitfalls in the non-invasive management of atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice while it has a significant impact on morbidity and mortality. The errors and pitfalls in the management of AF patients are not uncommon. These include errors in detection and management of the underlying conditions that promote and perpetuate the arrhythmia, in the selection and monitoring of antithrombotic treatment, in the selection of appropriate strategy for arrhythmia management (rate or rhythm control), in the cardioversion procedure, in the prevention of recurrence after cardioversion, in the acute or chronic control of heart rate, and in the monitoring of drug toxicities. The heterogeneity of the disease along with the diversity of current treatment options mainly account for these problems. Nevertheless, deep knowledge of the evidence-based therapeutic approaches, as well as the development of individualized therapeutic strategies, can substantially improve the effective management of such patients.

Predictors and prognosis of paroxysmal atrial fibrillation in general practice in the UK

Background

Natural history of paroxysmal atrial fibrillation (AF) is not very well documented. Clinical experience suggests that paroxysmal AF could progress to chronic AF with estimates ranging between 15 and 30% over a period of 1–3 years. We performed an epidemiologic study to elucidate the natural history of paroxysmal AF, this study estimated its incidence in a general practice setting, identified associated factors and analyzed the progression into chronic AF as well as the mortality rate.

Methods

Using the UK General Practice Research Database (GPRD), we identified patients aged 40–89 years with a first-recorded episode of paroxysmal AF during 1996. Risk factors were assessed using 525 incident paroxysmal AF cases confirmed by the general practitioner (GP) and a random sample of controls. We follow-up paroxysmal AF patients and estimated their mortality rate and progression to chronic AF.

Results

The incidence of paroxysmal AF was 1.0 per 1,000 person-years. Major risk factors for paroxysmal AF were age and prior valvular heart disease, ischaemic heart disease, heart failure and hyperthyroidism. During a mean follow-up of 2.7 years, 70 of 418 paroxysmal AF patients with complete information progressed to chronic AF. Risk factors associated with progression were valvular heart disease (OR 2.7, 95% CI 1.2–6.0) and moderate to high alcohol consumption (OR 3.0, 95% CI 1.1–8.0). Paroxysmal AF patients did not carry an increased risk of mortality, compared to an age and sex matched sample of the general population. There was a suggestion of a small increased risk among patients progressing to chronic AF (RR 1.5, 96% CI 0.8–2.9).

Conclusion

Paroxysmal AF is a common arrhythmia in the general practice setting, increasing with age and commonly associated with other heart diseases. It sometimes is the initial presentation and then progress to chronic AF. A history of valvular heart disease and alcohol consumption are associated with this progression.

Reflux esophagitis in the pathogenesis of paroxysmal atrial fibrillation: results of a pilot study

BACKGROUND

We sought to assess whether proton pump inhibitor (PPI) therapy of gastroesophageal reflux disease (GERD) in patients with lone paroxysmal atrial fibrillation (PAF) leads to a reduction of PAF-related symptoms.

METHODS

The records of patients with reflux esophagitis were screened for the diagnosis of lone PAF. All patients with reflux esophagitis and lone PAF were invited for a follow-up visit, at which PAF- and GERD-related symptoms, medication, and electrocardiogram were recorded.

RESULTS

Among 89 patients, 18 (6 women, aged 39-69 years) had lone PAF. Decrease or disappearance of at least one PAF-related symptom occurred in 14 of 18 patients (78%) after PPI therapy. In two of the remaining four patients, GERD-related symptoms persisted. Antiarrhythmic drugs were discontinued in five patients, and none had to be increased in dosage or newly prescribed. The electrocardiogram showed sinus rhythm in all patients.

CONCLUSION

In lone PAF, GERD should be investigated as a potential pathogenetic mechanism. PPI therapy reduces not only GERD-related but also PAF-related symptoms.