SHA24/026004

AF in in the the Gulf: Gulf: Patients’ Patients’ profile, profile, AF management and and one one year year outcomes outcomes management

Mohammad Zubaid, MB, ChB, FRCPC, FACC Professor of Medicine and Vice Dean for Academic Affairs, Faculty of Medicine, Kuwait University Head, Division of Cardiology, Mubarak Alkabeer Hospital Kuwait

ESC at the 24th Annual Conference of the Saudi Heart Association 2013 February 14, 2013, Riyadh, Saudi Arabia

Limited current literature on real-world AF management Prospective, observational registries on AF, up to June 2012, more than 100 patients and follow-up to 6 months Study

Year

Country

Patients

Follow-up (mths)

Centers

Follow– up

1991-1995

Canada

1,086

50

7

99%

2002

Sweden

2824

55

2

100%

Pappone et al

2002-2007

Italy

106

60

1

100%

Euro Heart Survey

2003-2004

Europe (35 countries)

5333

12

182

80%

AFIB Cameroon

2006-2007

Cameroon

172

11

10

51%

RecordAF

2007-2008

Europe, Americas, Asia (21 countries)

5814

12

532

90%

Belgrade AF Study

1992-2007

Serbia

1056

119

1

100%

AFFECTS

2005-2007

USA

1531

12

248

55%

Canadian Reg. of AF Stockholm Cohort Study of AF

*Hersi et al, J Saudi Heart Assoc 2012;24:243–252

Gulf SAFE Background



With an aging population, atrial fibrillation poses major global public health burden.



Observational registries are best suited to study what we do in our daily practice, whether guidelines are implemented and its impact on patients’outcomes.



Gulf SAFE is the only multinational, Middle Eastern, observational AF registry conducted to date.



The objectives were to study the characteristics of our AF patients, investigate how they are being managed and their real life outcomes.

*Hersi et al, J Saudi Heart Assoc 2012;24:243–252

Gulf SAFE Methods



All patients presenting to the emergency rooms (ER) and found to have AF on ECG lasting more than 30 seconds, were enrolled after signing consent form.



23 centres in 6 countries.



Primary diagnosis was not necessarily AF.



Follow up to ER or hospital discharge, then one, six and twelve months.



Paper CRF with online data entry system and quality control checking mechanisms.

Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

Gulf SAFE Distribution

Recruitment per country

(n=2,043)

69

NVAF = 1,721 379

Valvular AF = 322 605 459

124

407

Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

Gulf SAFE hospital characteristics (n=23) Hospital type Secondary

14 (61%)

Tertiary

9 (39%)

University

5 (22%)

Available Anti-arrhythmics Amiodarone

23 (100%)

Propafenone

12 (52%)

Flecanide

9 (39%)

Dedicated anticoagulation clinic

7 (30%)

EP lab on site

5 (22%)

Internists & Cardiologists admitting

13 (57%)

Internists & Cardiologists managing

6 (26%)

Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

Gulf SAFE - NVAF Baseline characteristics Characteristic Age, mean±SD, years Age ≥65 years Female gender Co-morbid conditions and risk factors Hypertension Diabetes Smoking CAD Heart failure LV systolic dysfunction COPD Thyroid disease Stroke TIA Body mass index, kg/m2 Overweight, 25 – 30 Obese, >30 LA diameter, mean±SD, mm First heart rate, mean±SD, bpm First SBP, mean±SD, mmHg

(n = 1,721) No. (%) 59.1±15.8 686 (39.9) 764 (44.4) 1,019 (59.2) 563 (32.7) 409 (23.8) 553 (32.1) 461 (26.8) 337 (19.6) 95 (5.5) 100 (5.8) 159 (9.2) 65 (3.8) 597 (37.0) 534 (33.1) 42.7±8.1 120±33 133±26

Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

Gulf SAFE - NVAF Baseline characteristics (n=1,721)

Gulf SAFE - NVAF Baseline characteristics (n=1,721)

Gulf SAFE - NVAF Baseline characteristics (n=1,721) CHADS2 score mean±SD = 1.6±1.4

Gulf SAFE - NVAF Pattern of anticoagulation

70

Recurrent NVAF (n=846)

60 50 40 Warfarin Prior

30 tag rcn e P

Warfarin at discharge

20 10 0 0

1 CHADS2 score

≼2

Gulf SAFE - NVAF Quality of anticoagulation

INR#3 was 279 (%) INR < 2.0

38

INR 2.0 to 3.0

46

INR > 3.0

16

Gulf SAFE â&#x20AC;&#x201C; 1,721 NVAF patients Rhythm management in ER 1,721 patients with non-valvular AF spontaneous cardioversion 172 (10%) 1,549 patients

Decided for rate control 1,110 (71.7%)

Admitted 898 (80.9%)

Admitted with Undecided strategy 56 (3.6%)

Decided for rhythm control 383 (24.7%)

Cardioversion Attempted in ER 259 (67.6%)

Admitted 181 (79.9%)

Admitted 129 (75%)

Electrical 34 (13.1%)

Amiodarone 150 (66.7%)

Admitted for in-hospital Cardioversion 124 (32.4%)

Pharmacological 225 (86.9%)

Propafenone 58 (25.8%)

Other 17 (7.5%)

Components of health care expenditure related to AF in the UK in 1995

Stewart S et al. Heart 2004;90:286-292

Gulf SAFE - NVAF One year outcomes

95% one year follow-up rate Event

Entire cohort

Reason for ER visit

Warfarin at discharge

AF

Cardiac

NonCardiac

No

Yes

No.(%) N=1,721

No.(%) N=827

No.(%) N=450

No.(%) N=444

No.(%) N=876

No.(%) N=778

263 (15)

35 (4.2)

90 (20)

138 (31)

95 (11)

101 (13)

Stroke/TIA

73 (4)

18 (2.2)

35 (8)

20 (5)

35 (4.0)

32 (4)

PE

3 (0.2)

0

0

3 (0.7)

1 (0.1)

2 (0.3)

20 (1.2)

2 (0.2)

7 (1.6)

11 (2.7)

8 (0.9)

12 (1.5)

11

2

3

6

5

6

Intracerebral

3

0

2

1

2

1

Subdural

2

0

1

1

0

2

Other

4

0

1

3

1

3

232 (14)

139 (17)

61 (14)

32 (8)

126 (14)

106 (14)

All-cause death

Major bleed Gastrointestinal

ER visit for AF

Gulf SAFE - NVAF Independent predictors of stoke/TIA in two logistic models

Gulf SAFE - NVAF Independent predictors of death Predictor Age Reason for ER Visit AF cardiac Non-cardiac Hypertension Diabetes mellitus CAD CHF Prior stroke/TIA PVD BMI Serum creatinine Anticoagulation at discharge Warfarin Aspirin/clopidogrel None

Adjusted OR 1.04

95% CI 1.03–1.05

P-value <0.001

Ref 2.46 5.99 0.64 1.34 1.34 2.64 1.41 2.26 0.96 1.01

Ref 1.51–4.02 3.74–9.61 0.43–0.95 0.92–1.93 0.77–1.64 1.79–3.89 0.91–2.19 1.01–5.08 0.93–0.99 1.01–1.01

Ref <0.001 <0.001 0.026 0.123 0.550 <0.001 0.126 0.048 0.012 <0.001

Ref 1.08 1.95

Ref 0.63–1.83 1.21–3.14

Ref 0.787 0.006

Gulf SAFE - NVAF Stroke or systemic embolism

Trial

CHADS2 score

% per year

RE-LY (warfarin arm)

2.1

1.69

ROCKET-AF (warfarin arm)

3.5

2.4

ARISTOTLE (warfarin arm)

2.1

1.6

Gulf SAFE on warfarin

1.8

4.7

Gulf SAFE - NVAF Conclusions



In our region, AF affects relatively young people with high risk profile.



Many patients received warfarin when they did not seem to be eligible for this treatment. While significant proportion of eligible patients did not receive warfarin.



The achieved anticoagulation levels were suboptimal in more than half of those who received it.

Gulf SAFE - NVAF Conclusions



The rhythm management in ER resulted in low rates of cardioversion attempts and high rates of hospital admission.



Despite the relatively young age, the outcomes of our AF population including stroke and mortality are not favorable.



Further analysis should explore the reason for this poor outcome and appropriate corrective measures should be taken.

Gulf SAFE Thanks

Steering Committee: Wafa A Rashed (Kuwait) Alawi A. Alsheikh-Ali (UAE) Ibrahim Al-Zakwani (Oman) Wael AlMahmeed (UAE) Abdullah Shehab (UAE) Kadhim Sulaiman (Oman) Ahmed Al Qudaimi (Yemen) Nidal Asaad (Qatar) Haitham Amin (Bahrain)

patients Nurses Colleagues Sanofi