Management and one year outcome of atrial fibrillation in Middle - PowerPoint PPT Presentation

Management and one year outcome of atrial fibrillation in Middle Eastern cohort enrolled in the observational Gulf Survey of Atrial Fibrillation Events (Gulf SAFE) Mohammad Zubaid, MB, ChB, FRCPC, FACC Professor of Medicine, Kuwait University Vice Dean for Academic Affairs, Faculty of Medicine Head, Division of Cardiology, Mubarak Alkabeer Hospital Kuwait Clinical Science: Special Reports: Valvular Heart Disease, PAD, AF: International Perspective AHA, November 7, 2012, Los Angeles

Gulf SAFE Background  With an aging population, Atrial fibrillation poses a major public health burden.  Guidelines have outlined the best treatment strategies for AF.  Gap exists between guidelines recommendations and physicians’ practice.  Observational registries best suited to study what we do in our daily practice and its impact on patients’ outcomes.  However, most observational AF registries carried out in North America and Europe.  Gulf SAFE is the only multinational, Middle Eastern, observational AF registry conducted so far.  The aim was to know who our AF patients are, how they are managed and their outcomes.

Gulf SAFE Methods  ER-based registry.  All patients coming to ER and found to have atrial fibrillation on ECG lasting more than 30 seconds.  Primary diagnosis was not necessarily AF.  Sign consent form.  Follow up to ER or hospital discharge, then one, six and twelve months.  Paper CRF with online data entry system/quality control checking mechanisms.  Six countries/23 centers. 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 Distribution Recruitment per country (n=2043) 69 379 605 459 407 124 Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

Gulf SAFE Baseline Characteristics Characteristic (n = 1,721) No. (%) Age, mean ± SD, years 59.1 ± 15.8 Age ≥65 years 686 (39.9) Female gender 764 (44.4) Co-morbid conditions and risk factors Hypertension 1,019 (59.2) Diabetes 563 (32.7) Smoking 409 (23.8) CAD 553 (32.1) Heart failure 461 (26.8) LV systolic dysfunction 337 (19.6) COPD 95 (5.5) Thyroid disease 100 (5.8) Stroke 159 (9.2) TIA 65 (3.8) Body mass index, kg/m 2 Overweight, 25 – 30 597 (37.0) Obese, >30 534 (33.1) LA diameter, mean ± SD, mm 42.7 ± 8.1 First heart rate, mean ± SD, bpm 120 ± 33 First SBP, mean ± SD, mmHg 133 ± 26 Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

Gulf SAFE Baseline characteristics (n = 1,721) 45 41.8 40 CHADS 2 score Mean ± SD =1.6 ± 1.4 35 60 Percentage 30 26.6 47.9 50 25 19.1 20 Percentage 40 15 9 10 27.1 30 3.5 25 5 0 20 10 0 Type of AF ≥2 0 1 CHADS 2 Score AF 22% HF ACS Chest Pain 48% 3% 4% Stroke Infection/Fever 5% Respiratory 5% 4% Other 9% Reason for ER Visit in Percentage

Gulf SAFE Rhythm management in ER 1,721 patients with non-valvular AF spontaneous cardioversion 172 (10%) 1,549 patients Admitted 129 (75%) Decided for Decided for Admitted with rate control rhythm control Undecided strategy 56 (3.6%) 1,110 (71.7%) 383 (24.7%) Admitted 898 (80.9%) Admitted for Cardioversion in-hospital Attempted Cardioversion in ER Admitted 124 (32.4%) 259 (67.6%) 181 (79.9%) Electrical Pharmacological 34 (13.1%) 225 (86.9%) Amiodarone Propafenone Other 150 (66.7%) 58 (25.8%) 17 (7.5%)

Non-valvular AF (n=1721)

Recurrent NVAF (n=846)

Gulf SAFE One year Outcomes 95% one year follow-up rate Event Entire Reason for ER visit Warfarin at discharge cohort AF Cardiac Non-Cardiac No Yes No.(%) No.(%) No.(%) No.(%) No.(%) No.(%) N=1,721 N=827 N=450 N=444 N=876 N=778 All-cause death 263 (15.3) 35 (4.2) 90 (20) 138 (31.1) 95 (10.8) 101 (13.0) Stroke/TIA 73 (4.2) 18 (2.2) 35 (7.8) 20 (4.5) 35 (4.0) 32 (4.1) PE 3 (0.2) 0 0 3 (0.7) 1 (0.1) 2 (0.3) Major bleed 20 (1.2) 2 (0.2) 7 (1.6) 11 (2.7) 8 (0.9) 12 (1.5) Gastrointestinal 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 ER visit for AF 232 (14.0) 139 (16.9) 61 (14.3) 32 (7.9) 126 (14.4) 106 (13.6) Admission for ER 183 (11.1) 101 (12.2) 54 (12.7) 28 (6.9) 92 (10.5) 91 (11.7) Admission for HF 175 (10.6) 44 (5.3) 92 (21.6) 39 (9.7) 67 (7.6) 108 (13.9)

Gulf SAFE Independent predictors of stroke/TIA in two logistic models Predictor OR 95% CI P-value Predictor OR 95% CI P-value Male 1.10 0.64 – 1.87 0.735 Male 1.23 0.72 – 2.13 0.449 Smoking 1.94 1.12 – 3.36 0.017 Smoking 2.01 1.16 – 3.47 0.013 Reason for ER Visit Reason for ER Visit AF Ref Ref Ref AF Ref Ref Ref Other cardiac 3.01 1.64 – 5.53 <0.001 Other cardiac 2.89 1.56 – 5.32 0.001 Non-cardiac 1.97 1.01 – 3.86 0.048 Non-cardiac 1.90 0.97 – 3.71 0.061 CHADS 2 score CHA 2 DS 2 -VASc score 0 Ref Ref Ref 0 Ref Ref Ref 1 2.18 0.92 – 5.18 0.078 1 1.60 0.48 – 5.38 0.448 2+ 3.01 1.34 – 6.76 0.008 2+ 3.47 1.29 – 9.35 0.014 Anticoagulation at Anticoagulation at discharge discharge None Ref Ref Ref None Ref Ref Ref Aspirin/clopidogrel 1.04 0.59 – 1.83 0.903 Aspirin/clopidogrel 1.03 0.59 – 1.82 0.907 Warfarin 0.38 0.17 – 0.83 0.015 Warfarin 0.39 0.18 – 0.84 0.016

Gulf SAFE independent predictors of death Predictor Adjusted OR 95% CI P-value Age 1.04 1.03 – 1.05 <0.001 Male 0.83 0.59 – 1.18 0.302 Reason for ER Visit AF Ref Ref Ref Other cardiac 2.46 1.51 – 4.02 <0.001 Non-cardiac 5.99 3.74 – 9.61 <0.001 Hypertension 0.64 0.43 – 0.95 0.026 Diabetes mellitus 1.34 0.92 – 1.93 0.123 CAD 1.34 0.77 – 1.64 0.550 CHF 2.64 1.79 – 3.89 <0.001 COPD 1.49 0.84 – 2.62 0.172 Prior stroke/TIA 1.41 0.91 – 2.19 0.126 PVD 2.26 1.01 – 5.08 0.048 BMI 0.96 0.93 – 0.99 0.012 Serum creatinine 1.01 1.01 – 1.01 <0.001 AF type First attack ever Ref Ref Ref Paroxysmal 1.01 0.60 – 1.73 0.959 Permanent 0.86 0.55 – 1.34 0.499 Persistent 1.44 0.78 – 2.67 0.241 Anticoagulation at discharge Warfarin Ref Ref Ref Aspirin/clopidogrel 1.08 0.63 – 1.83 0.787 None 1.95 1.21 – 3.14 0.006

Gulf SAFE Relation of warfarin at discharge with one year rate of stroke/TIA based on reason for ER visit

Relation of one year outcome and cause of admission

Stroke or systemic embolism Trial CHADS 2 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 CHADS 2 ≥ 2 on warfarin 2.6 5.1

Gulf SAFE - Conclusions  Gulf SAFE provides us with a unique opportunity to study AF and how it is being managed in the region.  While AF is primarily a disease of the elderly, in our region it affects relatively young people with high risk profile.  The anticoagulant management of our AF patients needs more attention.  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, heart failure and mortality are not favorable.  Further analysis should explore the reason for this poor outcome and appropriate corrective measures should be taken.