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