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

• 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
• utcomes.

Gulf SAFE Background

• 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.

Gulf SAFE Methods

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

Recruitment per country (n=2043) Gulf SAFE Distribution

605 69 407 124 459 379

Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

Gulf SAFE Baseline Characteristics

Zubaid et al, Circ Cardiovasc Qual Outcomes. 2011;4:477-482

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/m2 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

Gulf SAFE Baseline characteristics (n = 1,721)

41.8 19.1 26.6 9 3.5 5 10 15 20 25 30 35 40 45 Percentage Type of AF

48% 9% 5% 4% 5% 4% 3% 22%

Reason for ER Visit in Percentage AF HF ACS Chest Pain Stroke Infection/Fever Respiratory Other 25 27.1 47.9 10 20 30 40 50 60 1 ≥2 Percentage CHADS2 Score CHADS2 score Mean±SD =1.6±1.4

Gulf SAFE Rhythm management in ER

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

Non-valvular AF (n=1721)

Recurrent NVAF (n=846)

Gulf SAFE 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) 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 2 1 2 1 Subdural 2 1 1 2 Other 4 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 CHADS2 score CHA2DS2-VASc score Ref Ref Ref 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 discharge Anticoagulation at 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 CHADS2 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 CHADS2≥ 2 on warfarin 2.6 5.1

• 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.

Gulf SAFE - Conclusions