Mohammad Zubaid, MB, ChB, FRCPC, FACC

Transcription

1 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

2 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.

3 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:

4 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:

5 Distribution Recruitment per country (n=2043) Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:

6 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, (37.0) Obese, > (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:

7 Percentage Gulf SAFE Baseline characteristics (n = 1,721) Percentage CHADS2 score Mean±SD =1.6± Type of AF CHADS2 Score 22% AF HF 3% 4% 5% 48% ACS Chest Pain Stroke Infection/Fever Respiratory 4% 5% 9% Other Reason for ER Visit in Percentage

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

9 Non-valvular AF (n=1721)

10 Recurrent NVAF (n=846)

11 One year Outcomes 95% one year follow-up rate Event Entire cohort Reason for ER visit Warfarin at discharge AF Cardiac Non-Cardiac No Yes No.(%) N=1,721 No.(%) N=827 No.(%) N=450 No.(%) N=444 No.(%) N=876 No.(%) 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) (0.7) 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 Intracerebral Subdural Other 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)

12 Independent predictors of stroke/tia in two logistic models Predictor OR 95% CI P-value Predictor OR 95% CI P-value Male Male Smoking Smoking Reason for ER Visit Reason for ER Visit AF Ref Ref Ref AF Ref Ref Ref Other cardiac <0.001 Other cardiac Non-cardiac Non-cardiac CHADS 2 score CHA 2 DS 2 -VASc score 0 Ref Ref Ref 0 Ref Ref Ref Anticoagulation at discharge Anticoagulation at discharge None Ref Ref Ref None Ref Ref Ref Aspirin/clopidogrel Aspirin/clopidogrel Warfarin Warfarin

13 independent predictors of death Predictor Adjusted OR 95% CI P-value Age <0.001 Male Reason for ER Visit AF Ref Ref Ref Other cardiac <0.001 Non-cardiac <0.001 Hypertension Diabetes mellitus CAD CHF <0.001 COPD Prior stroke/tia PVD BMI Serum creatinine <0.001 AF type First attack ever Ref Ref Ref Paroxysmal Permanent Persistent Anticoagulation at discharge Warfarin Ref Ref Ref Aspirin/clopidogrel None

14 Relation of warfarin at discharge with one year rate of stroke/tia based on reason for ER visit

15 Relation of one year outcome and cause of admission

16 Stroke or systemic embolism Trial CHADS2 score % per year RE-LY (warfarin arm) ROCKET-AF (warfarin arm) ARISTOTLE (warfarin arm) Gulf SAFE on warfarin Gulf SAFE CHADS2 2 on warfarin

17 - 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.