Summary
Background
The implementation of international guidelines for antithrombotic use in atrial fibrillation (AF) in routine practice is not well known, particularly, in some parts of the world, such as the Middle East and Africa.
Aim
To describe and analyse the use of antithrombotics in patients with AF in routine practice.
Methods
The RealiseAF international cross-sectional survey enrolled 10,523 patients (with at least one documented AF episode in the preceding 12 months) from 831 sites. Participating physicians were randomly selected from physician list forms.
Results
Mean age was 66.6 ± 12.2 years. In 47.4% of the patients with a CHADS 2 score ≥ 2, oral anticoagulants were not prescribed. Patients who had a CHADS 2 score ≥ 2, permanent or persistent AF, valvular heart disease, a stroke leading to hospitalization in the previous year or treatment by a cardiologist (rather than an internist) were most likely to receive oral anticoagulants. Patients aged ≥ 75 years and those with coronary heart disease; major bleeding leading to hospitalization in the previous year or a rhythm control strategy was least likely to receive oral anticoagulants. Appropriate antithrombotic treatment was prescribed in 66.7% of the patients with a CHADS 2 score ≥ 2 in the Middle East/Africa, 55.3% in Europe, 43.9% in Latin America and 31.7% in Asia.
Conclusion
There is substantial deviation from international guidelines in antithrombotic use for AF in routine clinical practice, with overuse and underuse of antithrombotics in about 50% of the cases and important geographical differences. These findings emphasize the need for improved medical education worldwide and a better understanding of geographical disparities in the implementation of guidelines.
Résumé
Contexte
L’impact des recommandations internationales dans la pratique courante concernant l’utilisation d’antithrombotiques dans la fibrillation atriale (FA) n’est pas bien connu particulièrement dans certaines parties du monde comme le Moyen Orient et l’Afrique.
Objectif
Décrire et analyser l’utilisation d’antithrombotiques chez les patients souffrant de FA dans la pratique courante.
Méthodologie
L’enquête croisée internationale RealiseAF incluait 10 523 patients (avec ≥ 1 épisode de FA documenté au cours des 12 mois précédents) dans 831 centres. Les médecins participants ont été sélectionnés par tirage au sort à partir de listes de médecins.
Résultats
La moyenne d’âge était de 66,6 ± 12,2 ans. Chez 47,4 % des patients présentant un score CHADS 2 ≥ 2, aucun anticoagulant oral (ACO) n’a été prescrit. Les patients présentant des scores CHADS 2 ≥ 2, avec une FA permanente ou persistante et une cardiopathie valvulaire, qui avaient présenté un AVC nécessitant une hospitalisation au cours de l’année précédente et qui avaient été traités par un cardiologue (plutôt qu’un interniste), étaient plus enclins à recevoir des ACO. Les patients âgés de 75 ans et plus, souffrant d’une coronaropathie et ayant développé un saignement majeur nécessitant une hospitalisation au cours de l’année précédente, et les patients faisant l’objet d’une stratégie de contrôle du rythme, étaient moins enclins à recevoir des ACO. Un traitement antithrombotique adapté a été prescrit chez 66,7 % des patients présentant un score CHADS 2 ≥ 2 au Moyen Orient/en Afrique, 55,3 % des patients en Europe, 43,9 % des patients en Amérique latine et 31,7 % des patients en Asie.
Conclusion
On observe une déviation considérable par rapport aux recommandations internationales concernant l’utilisation d’antithrombotiques pour la FA dans la pratique clinique, avec une sur-utilisation et une sous-utilisation des antithrombotiques dans environ 50 % des cas, et avec d’importantes différences géographiques. Ces résultats soulignent la nécessité d’une meilleure éducation médicale et d’une meilleure compréhension des disparités géographiques dans la mise en application des recommandations.
Background
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting 1–2% of the general population . A crucial aspect of AF management is the prevention of stroke, using antithrombotic therapy (anti-platelets and oral anticoagulants [OACs]) . Although international guidelines provide simple rules for the use of antithrombotics in patients with AF, the implementation of these guidelines in routine practice around the globe, particularly outside Europe and North America, is not well known .
The real-life global survey evaluating patients with AF (RealiseAF) survey was established to investigate patient characteristics, cardiovascular risk, types of AF, symptoms and medical history and management practices, including the use of antithrombotics , in routine clinical practice, across a broad range of geographic settings worldwide. The present analysis aimed to describe the use and determinants of use of antithrombotic agents in patients with AF in the regions participating in the RealiseAF survey.
Methods
Design
As previously reported, RealiseAF was a cross-sectional observational survey that enrolled 10,546 patients with AF at 831 sites in 26 countries, from October 2009 to May 2010 .
Patients
To be eligible for enrolment, patients had to have a history of AF (treated or untreated), with at least one AF episode documented by standard electrocardiogram or Holter electrocardiogram in the last 12 months, or documented current AF. Exclusion criteria included mental disability, inability to provide written informed consent, AF occurring within 3 months of cardiac surgery, and participation in clinical trials in the AF or antithrombotic field in the previous month. All patients provided written informed consent. Participating physicians were randomly selected from physician list forms . Twenty-six countries from four continents participated in the survey ( Appendix A ).
Objectives
The main objectives of the present analysis were to describe the use of antithrombotic agents among the RealiseAF patients as a function of the CHADS 2 score (Congestive heart failure, Hypertension, Age > 75 years, Diabetes mellitus and Stroke or transient ischaemic attack [2 points]); to assess compliance with the 2006 American College of Cardiology (ACC)/American Heart Association (AHA)/European Society of Cardiology (ESC) guidelines (which are relevant to patients enrolled between 2009 and 2010) ; and to analyse the results according to geographic region and type of AF (paroxysmal, persistent or permanent). In this analysis, the CHADS 2 score was also calculated in patients with valvular disease.
Statistical analyses
Details of how the sample size was determined have been described previously . Population characteristics were summarized by means ± standard deviations for continuous variables and by counts (percentages) for qualitative variables. Comparisons between subgroups were made using the chi 2 test or analysis of variance as appropriate. To identify factors associated with use of OACs in AF patients with a CHADS 2 score ≥ 2, a multivariable stepwise logistic regression was performed, using a P value of 0.05 to retain the variable in the model. Variables tested were: age by class; obesity; hypertension; left ventricular hypertrophy; history of heart failure by New York Heart Association class; history of coronary artery disease; history of cerebrovascular disease; history of valvular heart disease; type of AF; time since AF diagnosis by class; AF management strategy chosen before the enrolment visit; major bleeding leading to hospitalization in the last 12 months; stroke leading to hospitalization in the last 12 months; and speciality of physician and practice (public/private). Discrimination was assessed using c -statistics and calibration was assessed using Hosmer–Lemeshow statistics. The odds ratios and associated 95% confidence intervals for the use of OACs were determined. Multivariable analysis was adjusted for country. Analyses were performed using SAS ® statistical software, version 9.2 (SAS Institute, Cary, NC, USA).
Results
Participating physicians
A total of 831 physicians participated in the survey. Among these, information regarding speciality was available for 803. The majority were cardiologists (667/803; 83.1%), while around 1 in 10 were internists (63/803; 7.8%) or reported both specialities (cardiologist and internist, 73/803; 9.1%).
Patient characteristics
Of the 10,546 patients enrolled, 10,523 constituted the analysed population. Twenty-three patients were ineligible, due to no history of AF ( n = 6), mental illness ( n = 1), post-cardiac surgery AF ( n = 1), clinical trial in AF or antithrombotic treatment in the previous month ( n = 3) or other reasons ( n = 14) (one patient had three reasons for ineligibility). Patients had a mean age of 66.6 ± 12.2 years and 56.4% were male. AF was paroxysmal in 24.8%, persistent in 22.3% and permanent in 46.4% of patients; the remaining 6.4% had their first episode of AF, thereby, preventing assignation to one of the previous categories.
Among the RealiseAF population, 12.5% of the patients had a CHADS 2 score of 0, 27.9% had a score of 1 and 59.6% had a score of ≥ 2. Consistent with the elements constituting the score, the population of patients with a CHADS 2 score ≥ 2 was older, had a higher prevalence of cardiovascular risk factors, particularly diabetes and hypertension, and was more likely to have permanent AF and heart failure ( Table 1 ). Patient characteristics according to region and type of AF are presented in Tables 2 and 3 .
| Characteristic | CHADS 2 score | P | ||
|---|---|---|---|---|
| 0 ( n = 1262) | 1 ( n = 2810) | ≥ 2 ( n = 6004) | ||
| Age (years) | 55.3 ± 12.3 | 62.6 ± 10.8 | 70.7 ± 10.5 | < 0.0001 |
| Age ≥ 75 years | 0 | 8.1 | 42.7 | < 0.0001 |
| Male | 62.7 | 57.4 | 54.4 | < 0.0001 |
| Type of AF | < 0.0001 | |||
| Paroxysmal | 32.1 | 29.6 | 21.5 | |
| Persistent | 24.2 | 23.8 | 21.3 | |
| Permanent | 33.4 | 39.4 | 52.3 | |
| First episode | 10.2 | 7.1 | 5.0 | |
| Paroxysmal + persistent | < 0.1 | 0 | 0 | |
| Hypertension | 0 | 64.5 | 90.2 | < 0.0001 |
| Diabetes mellitus | 0 | 4.1 | 33.5 | < 0.0001 |
| Obesity, BMI ≥ 30 kg/m 2 | 20.2 | 32.2 | 35.8 | < 0.0001 |
| Smoking | < 0.0001 | |||
| Current smoker | 14.0 | 10.5 | 9.1 | |
| Never or former smoker | 86.0 | 89.5 | 90.9 | |
| Dyslipidaemia | 21.5 | 36.9 | 55.6 | < 0.0001 |
| Heart failure in class | < 0.0001 | |||
| No HF or NYHA class I | 100 | 80.4 | 43.1 | |
| NYHA class II | 0 | 11.5 | 36.1 | |
| NYHA class III or IV | 0 | 8.1 | 20.8 | |
| Coronary artery disease | 8.3 | 18.4 | 43.4 | < 0.0001 |
| Valvular heart disease | 23.3 | 25.4 | 27.5 | 0.0033 |
| PCI in the last 12 months | 2.4 | 4.1 | 8.0 | < 0.0001 |
| AF management strategy chosen for AF before this visit | < 0.0001 | |||
| Rhythm control | 41.9 | 40.9 | 30.6 | |
| Rate control | 39.1 | 47.6 | 59.7 | |
| Rhythm control + rate control | 0 | 0.1 | < 0.1 | |
| None | 19.0 | 11.4 | 9.7 | |
| Characteristic | Region | P | |||
|---|---|---|---|---|---|
| Asia ( n = 1703) | Europe ( n = 6759) | Latin America ( n = 381) | Middle East/Africa ( n = 1680) | ||
| Age (years) | 66.4 ± 13.1 | 68.1 ± 10.8 | 66.0 ± 13.6 | 61.1 ± 14.2 | < 0.0001 |
| Age ≥ 75 years | 31.1 | 29.6 | 30.4 | 17.9 | < 0.0001 |
| Male | 54.1 | 59.6 | 57.0 | 45.8 | < 0.0001 |
| Type of AF | < 0.0001 | ||||
| Paroxysmal | 26.1 | 26.5 | 23.8 | 17.2 | |
| Persistent | 17.9 | 24.0 | 14.6 | 21.6 | |
| Permanent | 48.2 | 44.3 | 57.1 | 50.5 | |
| First episode | 7.8 | 5.1 | 4.5 | 10.7 | |
| Paroxysmal + persistent | < 0.1 | < 0.1 | 0 | 0 | |
| Hypertension | 67.5 | 78.1 | 66.3 | 54.7 | < 0.0001 |
| Diabetes mellitus | 24.9 | 20.2 | 19.7 | 22.7 | 0.0001 |
| Obesity, BMI ≥ 30 kg/m 2 | 18.7 | 35.9 | 36.5 | 33.0 | < 0.0001 |
| Smoking | < 0.0001 | ||||
| Current smoker | 10.0 | 9.6 | 5.2 | 13.7 | |
| Never or former smoker | 90.0 | 90.4 | 94.8 | 86.3 | |
| Dyslipidaemia | 35.1 | 54.1 | 38.8 | 27.9 | < 0.0001 |
| Heart failure in class | < 0.0001 | ||||
| No HF or NYHA class I | 64.3 | 56.8 | 68.0 | 66.9 | |
| NYHA class II | 21.8 | 27.9 | 25.2 | 16.5 | |
| NYHA class III or IV | 13.9 | 15.3 | 6.8 | 16.6 | |
| Coronary artery disease | 32.8 | 36.4 | 16.3 | 19.1 | < 0.0001 |
| Valvular heart disease | 38.6 | 22.2 | 31.8 | 31.5 | < 0.0001 |
| PCI in the last 12 months | 6.4 | 6.1 | 3.9 | 7.2 | 0.0964 |
| AF management strategy chosen for AF before this visit | < 0.0001 | ||||
| Rhythm control | 23.2 | 39.4 | 33.1 | 26.7 | |
| Rate control | 60.4 | 51.3 | 60.6 | 55.4 | |
| Rhythm control + rate control | < 0.1 | < 0.1 | 0 | 0 | |
| None | 16.3 | 9.2 | 6.3 | 17.9 | |
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