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

Abstract

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 (Outpatient Registry 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 CHADS(2) 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.

Fig. 1

CHA₂DS₂-VASc score. Score points based on available data for the calculation of the score in 3,667 patients

Fig. 2

Numbers of concomitant conditions, by AF type. Risk factors: age ≥75 years, arterial hypertension, diabetes mellitus and chronic heart failure. Values are missing for AF type in 204 patients and for concomitant conditions in 18 patients

Fig. 3

Antithrombotic prophylaxis and oral anticoagulation (OAC) in patients with various eligibility categories for OAC by CHADS2 or CHA₂DS₂-VASc. Score 0 (=no risk factor) = no OAC recommended; Score 1 (=only 1 non-major risk factor) = either ASS or OAC recommended, OAC preferred; Score ≥2 (=at least 1 major or at least 2 non-major risk factors) = OAC recommended. Information on antithrombotic prophylaxis and oral anticoagulation was missing in 409 patients