Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events--European Registry in Atrial Fibrillation (PREFER in AF)

Abstract

Aims: We sought to describe the management of patients with atrial fibrillation (AF) in Europe after the release of the 2010 AF Guidelines of the European Society of Cardiology.

Methods and results: The PREFER in AF registry enrolled consecutive patients with AF from January 2012 to January 2013 in 461 centres in seven European countries. Seven thousand two hundred and forty-three evaluable patients were enrolled, aged 71.5 ± 11 years, 60.1% male, CHA2DS2VASc score 3.4 ± 1.8 (mean ± standard deviation). Thirty per cent patients had paroxysmal, 24.0% had persistent, 7.2% had long-standing persistent, and 38.8% had permanent AF. Oral anticoagulation was used in the majority of patients: 4799 patients (66.3%) received a vitamin K antagonist (VKA) as mono-therapy, 720 patients a combination of VKA and antiplatelet agents (9.9%), 442 patients (6.1%) a new oral anticoagulant drugs (NOAC). Antiplatelet agents alone were given to 808 patients (11.2%), no antithrombotic therapy to 474 patients (6.5%). Of 7034 evaluable patients, 5530 (78.6%) patients were adequately rate controlled (mean heart rate 60-100 bpm). Half of the patients (50.7%) received rhythm control therapy by electrical cardioversion (18.1%), pharmacological cardioversion (19.5%), antiarrhythmic drugs (amiodarone 24.1%, flecainide or propafenone 13.5%, sotalol 5.5%, dronedarone 4.0%), and catheter ablation (5.0%).

Conclusion: The management of AF patients in 2012 has adapted to recent evidence and guideline recommendations. Oral anticoagulant therapy with VKA (majority) or NOACs is given to over 80% of eligible patients, including those at risk for bleeding. Rate is often adequately controlled, and rhythm control therapy is widely used.

Keywords: Adherence to guidelines; Antiarrhythmic drugs; Anticoagulation; Atrial fibrillation; Catheter ablation; Guidelines; Management; Rate control; Registry; Rhythm control; Stroke.

Figure 1

Proportion of patients with a given AF pattern (paroxysmal, persistent, long-standing persistent, or permanent, plotted as percentage, y axis) in the study population plotted by the number of concomitant cardiovascular diseases and age as summarized in the CHA₂DS₂VASc score (x axis). The proportion of patients with permanent AF increases in each CHA₂DS₂VASc stratum, while the proportion of patients with paroxysmal AF decreases.

Figure 2

Use of antithrombotic therapy by stroke risk. Most patients with a high stroke risk received adequate anticoagulation, mainly delivered as vitamin K antagonist therapy, antiplatelet agent. VKA vitamin K antagonist, NOAC new oral anticoagulant, OAC oral anticoagulation (either VKA or NOAC).

Figure 3

Therapeutic effect of vitamin K antagonist therapy, expressed as the number of the last three INR values prior to enrolment that were within the therapeutic range, split by the different vitamin K antagonists used. INR, international normalized ratio.

Figure 4

Use of rhythm control therapy options by patient symptoms. Following clinical reasoning and the recommendations in the ESC guidelines, rhythm control therapy was rarely used in asymptomatic patients. The EHRA score is calculated as the maximum of the six symptoms score (palpitations, fatigue, dizziness, dyspnea, chest pain, anxiety) as explained in the legend to Table 3.

Figure 5

Type of rhythm control therapy by type of heart disease. (A) Stacked column graph depicting the use of the different antiarrhythmic drugs and catheter ablation in patients with different types of heart disease (coronary artery disease, heart failure, no structural heart disease). (B) Illustration of the use of rhythm control therapies in patients with different types of heart disease in a flow chart illustrating the recommendations of the ESC 2010 guidelines for AF. All numbers reflect the actual patient number.