Global Variations in the 1-year Rates of Death and Stroke in Patients Presenting to the Emergency Department with Atrial Fibrillation

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1 Global Variations in the 1-year Rates of Death and Stroke in Patients Presenting to the Emergency Department with Atrial Fibrillation Results from the RE-LY AF Registry

2 Presenter Disclosure Information Jeff S. Healey, MD, MSc, McMaster University, Canada Sub-clinical atrial tachyarrhythmia and stroke FINANCIAL DISCLOSURES: Grants/Research Support: Boston Scientific, St. Jude Medical, Boehringer Ingelheim and Astra-Zeneca The ASSERT trial was sponsored by St. Jude Medical Principal Investigator of SIMPLE randomized trial of DFT Testing at time of ICD implantation Advisory Boards: Sanofi-Aventis, Boehringer Ingelheim UNLABELED/UNAPPROVED USES DISCLOSURE: None

3 Background AF is a major global disease; however, our understanding of AF is based largely on European and N. American studies Baseline results from the RE-LY AF registry (ESC 2011) demonstrated important regional variations in risk factors and treatment of AF The RE-LY AF registry followed patients for 1 year to document: Cause-specific mortality Clinical outcomes including stroke, embolism, heart failure, major bleeding and hospitalization

4 47 countries; 164 sites; 15,408 patients = Participating country Region Sites Patients Middle East North America Africa Latin America India Western Europe China Eastern Europe SE Asia

5 Study Methods Prospective registry Atrial fibrillation or atrial flutter Primary or secondary diagnosis Presenting to an emergency department Enrolled between January 2008 and April 2011 Follow-up completed May 2012 Occurred 1 year ± 4 weeks after enrolment Complete FU in 99.4% Complete reporting of ALL data in 97.7%

6 Arrhythmia Patient Characteristics Atrial fibrillation: 98%; Atrial flutter: 2% Reason for ER visit AF primary diagnosis: 44%; Secondary: 56% History of AF First episode: 21%; Prior history: 79% Pattern of AF Paroxysmal AF: 34% Persistent AF: 26% Permanent AF: 40%

7 Age Median; IQR (years) N. Am S. Am W. Eur E. Eur Middle E. Africa India China SE Asia

8 Mean CHADS 2 Score 2,5 2,0 1,5 1,0 0,5 0,0 N. Am S. Am W. Eur E. Eur Middle E. Africa India China SE Asia

9 Mortality at 1-year in regional cohorts 25% 20% 15% 10% Global Ave. 5% 0% N. Am S. Am W. Eur E. Europe Middle E. Africa India China SE Asia Crude Mortality Adjusted Mortality: (for age, sex, heart failure, coronary artery disease, hypertension, diabetes, rheumatic heart disease and reason for emergency department presentation)

10 Mortality: by Reason for ED Visit 30% 25% 20% 15% 10% 5% Global Ave. 0% N. Am S. Am W. Eur E. Europe Primary Diagnosis of AF Other Primary Diagnosis Middle E. Africa India China SE Asia

11 Cause of Death: Global 40% 35% 30% 25% 20% 15% 10% 5% 0% Heart Failure Infection Stroke Resp. Failure Cancer Sudden Death MI Proportion of all Deaths

12 Proportion of Causes of Death by Region 100% 90% 80% 70% 60% 50% 40% Stroke Heart Failure 30% 20% 10% 0% N. Am S. Am W. Eur E. Eur M. East Africa India China SE Asia

13 Stroke rates in the regional cohorts 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% N. Am S. Am W. Eur E. Europe Middle E. Africa India China SE Asia Crude Stroke Rate Adjusted Stroke Rate: (for age, stroke/tia, heart failure, hypertension, diabetes and VITAMIN K ANTAGONIST USE) Global Ave. (Crude)

14 Stroke Rates: Overall Global by RHD N=1788 patients with RHD 5,0% 4,5% 4,0% 3,5% 3,0% 2,5% 2,0% 1,5% 1,0% 0,5% 0,0% Crude *Adjusted No History of Rheumatic Heart Disease History of Rheumatic Heart Disease No Rheumatic Heart Disease N=13,507 Rheumatic Heart Disease N=1788 Age 66.2 years 49.5 years Female sex 45.4% 64.9% Coronary Disease 34.3% 5.5% Hypertension 60.3% 19.6% Heart Failure 33.0% 34.7% Warfarin Use 32.0% 68.7% *Adjusted for age, history of stroke/tia, heart failure, diabetes, hypertension, region and VKA use

15 Global CHADS 2 -Specific Stroke Rate (1-yr.) 14% 12% 10% 8% 6% 4% 2% 0% > 3 Proportion of Patients with Stroke at 1 year, without RHD Proportion of Patients with Stroke at 1 year, with RHD, but no valve surgery CHADS2: Congestive Heart Failure, Hypertension, Age 75, Diabetes Mellitus, Prior Stroke or TIA (2)

16 Conclusions In a global setting more than 10% of patients presenting to an emergency department with AF are dead within 1 year The rate appears highly variable between different countries However; may be unmeasured bias in types of patients recruited Mortality is 2-3 times higher when AF is a secondary diagnosis Despite the availability of modern medical therapy, more than 4% of AF patients experience stroke within one year Globally, CHADS 2 score has a greater influence on stroke risk than the presence of rheumatic heart disease Most of the difference in stroke rate between regions can be explained on the basis of regional differences in patient characteristics and the use of vitamin K antagonists

17 Conclusions II In a global setting the RELY AF registry shows very large unmet medical needs and large opportunities for improvement by applying currently generally available modalities for diagnosis, risk stratification and treatment of patients presenting with atrial fibrillation

18 Acknowledgements Steering committee J. Healey*, S. Connolly, S. Yusuf (Canada); J. Oldgren*, L. Wallentin (Sweden); M. Ezekowitz, A. Parekh (USA); A. Avezum (Brazil); P. Jansky (Czech Republic); P. Commerford (South Africa); J. Zhu, Lisheng Liu (China); P. Pais, A. Sigamani (India); A. Damasceno (Mozambique). * co-chairs Study Coordination A. Grinvalds, E. Themeles (Canada) Population Health Research Institute (Canada); Dante Pazzanese Institute Research Division(Brazil); St. John s Research Institute (India); Fuwai Hospital (China) Study Sponsor Boehringer-Ingelheim: P. Reilly, J. Varrone

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