Advertisement

Use of Evidence-based Cardiac Prevention Therapy Among Outpatients with Atrial Fibrillation

      Abstract

      Background

      Patients with atrial fibrillation often have cardiovascular risk factors or known comorbid disease, yet the use of evidence-based primary and secondary prevention cardiac therapy among atrial fibrillation outpatients is unknown.

      Methods

      Using baseline data collected between June 2010 and August 2011 from 174 sites participating in ORBIT-AF, a US national registry of patients with atrial fibrillation coordinated from Durham, NC, we examined professional guideline-recommended evidence-based therapy use for cardiovascular comorbid conditions and risk factors. Multivariable logistic regression was used to identify factors associated with receipt of all indicated evidence-based therapy.

      Results

      Among 10,096 enrolled patients, 93.5% were eligible for one or more evidence-based therapies. Among those eligible, 46.6% received all indicated therapies: 62.3% received an antiplatelet agent, 72.3% received a beta-blocker, 59.5% received an angiotensin-converting enzyme or angiotensin receptor blocker, 15.3% received an aldosterone antagonist, 65.7% received a statin, and 58.8% received an implantable cardioverter-defibrillator. A minority of patients with coronary artery disease, diabetes mellitus, heart failure, and peripheral vascular disease received all indicated therapies (25.1%, 43.2%, 42.5%, and 43.4%, respectively). A total of 52.4% of patients had controlled hypertension and 74.6% of patients with hyperlipidemia received a statin. Factors associated with nonreceipt of all indicated therapies included frailty, comorbid illness, geographic region, and antiarrhythmic drug therapy.

      Conclusions

      The majority of eligible atrial fibrillation outpatients did not receive all guideline-recommended therapies for cardiovascular comorbid conditions and risk factors. This represents a potential opportunity to improve atrial fibrillation patients' quality of care and outcomes.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Braunwald E.
        Shattuck lecture—cardiovascular medicine at the turn of the millenium: Triumphs, concerns, and opportunities.
        N Engl J Med. 1997; 337: 1360-1369
        • Lloyd-Jones D.M.
        • Wang T.J.
        • Leip E.P.
        • et al.
        Lifetime risk for development of atrial fibrillation: the Framingham Heart Study.
        Circulation. 2004; 110: 1042-1046
        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Heart disease and stroke statistics—2012 update: a report from the American Heart Association.
        Circulation. 2012; 125: e2-e220
        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Heart disease and stroke statistics—2011 update: a report from the American Heart Association.
        Circulation. 2011; 123: e18-e209
        • Go A.S.
        • Hylek E.M.
        • Phillips K.A.
        • et al.
        Prevalence of diagnosed atrial fibrillation in adults; national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study.
        JAMA. 2001; 285: 2370-2375
        • Wolf P.A.
        • Dawber T.R.
        • Thomas E.
        • Kannel W.B.
        Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham Heart Study.
        Neurology. 1978; 28: 973-977
        • Benjamin E.J.
        • Wolf P.A.
        • D'Agostino R.B.
        • Silbershatz H.
        • Kannel W.B.
        • Levy D.
        Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.
        Circulation. 1998; 98: 946-952
        • Wang T.J.
        • Massaro J.M.
        • Levy D.
        • et al.
        A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham Heart Study.
        JAMA. 2003; 290: 1049-1056
        • Lip G.Y.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.J.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • Conen D.
        • Chae C.U.
        • Glynn R.J.
        • et al.
        Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation.
        JAMA. 2011; 305: 2080-2087
        • Jahangir A.
        • Lee V.
        • Friedman P.A.
        • et al.
        Long-term progression and outcomes with aging in patients with lone atrial fibrillation: a 30-year follow-up study.
        Circulation. 2007; 115: 3050-3056
        • Piccini J.P.
        • Fraulo E.S.
        • Ansell J.E.
        • et al.
        Outcomes registry for better informed treatment of atrial fibrillation: rationale and design of ORBIT-AF.
        Am Heart J. 2011; 162 (606.e1–612.e1)
        • Smith Jr., S.C.
        • Benjamin E.J.
        • Bonow R.O.
        • et al.
        AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
        Circulation. 2011; 124: 2458-2473
        • Jessup M.
        • Abraham W.T.
        • Casey D.E.
        • et al.
        2009 focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.
        Circulation. 2009; 119: 1977-2016
        • Rooke T.W.
        • Hirsch A.T.
        • Misra S.
        • et al.
        2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.
        Circulation. 2011; 124: 2020-2045
      1. American Diabetes Association. Standards of medical care in diabetes—2011.
        Diabetes Care. 2011; 34: S11-S61
        • Grundy S.M.
        • Cleeman J.I.
        • Merz C.N.
        • et al.
        Implications of recent clinical trials for the National Cholesterol Education Program adult treatment panel III guidelines.
        Circulation. 2004; 110: 227-239
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • et al.
        The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report.
        JAMA. 2003; 289: 2560-2572
        • Hess P.L.
        • Greiner M.A.
        • Fonarow G.C.
        • et al.
        Outcomes associated with warfarin use in older patients with heart failure and atrial fibrillation and a cardiovascular implantable electronic device: findings from the ADHERE registry linked to medicare claims.
        Clin Cardiol. 2012; 35: 649-657
        • Nasr I.A.
        • Bouzamondo A.
        • Hulot J.S.
        • Dubourg O.
        • Le Heuzey J.Y.
        • Lechat P.
        Prevention of atrial fibrillation onset by beta-blocker treatment in heart failure: A meta-analysis.
        Eur Heart J. 2007; 28: 457-462
        • Liu T.
        • Li L.
        • Korantzopoulos P.
        • Liu E.
        • Li G.
        Statin use and development of atrial fibrillation: a systematic review and meta-analysis of randomized clinical trials and observational studies.
        Int J Cardiol. 2008; 126: 160-170
        • Schneider M.P.
        • Hua T.A.
        • Bohm M.
        • Wachtell K.
        • Kjeldsen S.E.
        • Schmieder R.E.
        Prevention of atrial fibrillation by renin-angiotensin system inhibition: A meta-analysis.
        J Am Coll Cardiol. 2010; 55: 2299-2307
        • Ueng K.C.
        • Tsai T.P.
        • Yu W.C.
        • et al.
        Use of enalapril to facilitate sinus rhythm maintenance after external cardioversion of long-standing persistent atrial fibrillation.
        Eur Heart J. 2003; 24: 2090-2098
        • Madrid A.H.
        Use of irbesartan to maintain sinus rhythm in patients with long-lasting persistent atrial fibrillation: a prospective and randomized study.
        Circulation. 2002; 106: 331-336
        • Williams R.S.
        • deLemos J.A.
        • Dimas V.
        • Reisch J.
        • Hill J.A.
        • Naseem R.H.
        Effect of spironolactone on patients with atrial fibrillation and structural heart disease.
        Clin Cardiol. 2011; 34: 415-419
        • Fauchier L.
        • Pierre B.
        • de Labriolle A.
        • Grimard C.
        • Zannad N.
        • Babuty D.
        Antiarrhythmic effect of statin therapy and atrial fibrillation: a meta-analysis of randomized controlled trials.
        J Am Coll Cardiol. 2008; 51: 828-835
        • Fuster V.
        • Ryden L.E.
        • Cannom D.S.
        • et al.
        2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.
        Circulation. 2011; 123: e269-e367
        • Fonarow G.C.
        • Albert N.M.
        • Curtis A.B.
        • et al.
        Improving evidence-based care for heart failure in outpatient cardiology practices: primary results of the registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF).
        Circulation. 2010; 122: 585-596
        • Gaede P.
        • Lund-Anderson H.
        • Parving H.H.
        • Pedersen O.
        Effect of a multifactorial intervention on mortality in type 2 diabetes.
        N Engl J Med. 2008; 358: 580-591
        • Newby L.K.
        • LaPointe N.M.
        • Chen A.Y.
        • et al.
        Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease.
        Circulation. 2006; 113: 203-212
        • Saydah S.H.
        • Fradkin J.
        • Cowie C.C.
        Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.
        JAMA. 2004; 291: 335-342
        • Fonarow G.C.
        • Yancy C.W.
        • Albert N.M.
        • et al.
        Heart failure care in the outpatient cardiology practice setting: Findings from IMPROVE HF.
        Circ Heart Fail. 2008; 1: 98-106
        • Jackevicius C.A.
        • Mamdani M.
        • Tu J.V.
        Adherence with statin therapy in elderly patients with and without acute coronary syndromes.
        JAMA. 2002; 288: 462-467
        • Egan B.M.
        • Zhao Y.
        • Axon R.N.
        US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008.
        JAMA. 2010; 303: 2043-2050
        • Hirsch A.T.
        • Criqui M.H.
        • Treat-Jacobson D.
        • et al.
        Peripheral arterial disease detection, awareness, and treatment in primary care.
        JAMA. 2001; 286: 1317-1324
        • Afilalo J.
        • Karunananthan S.
        • Eisenberg M.J.
        • Alexander K.P.
        • Bergman H.
        Role of frailty in patients with cardiovascular disease.
        Am J Cardiol. 2009; 103: 1616-1621
        • Flint K.M.
        • Matlock D.D.
        • Lindenfeld J.
        • Allen L.A.
        Frailty and the selection of patients for destination therapy left ventricular assist device.
        Circ Heart Fail. 2012; 5: 286-293
        • Alexander K.P.
        • Newby L.K.
        • Cannon C.P.
        • et al.
        Acute coronary care in the elderly, part I: non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology.
        Circulation. 2007; 115: 2549-2569
        • Alexander K.P.
        • Newby L.K.
        • Armstrong P.W.
        • et al.
        Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology.
        Circulation. 2007; 115: 2570-2589
        • Boutitie F.
        • Boissel J.P.
        • Connolly S.J.
        • et al.
        Amiodarone interaction with beta-blockers: analysis of the merged EMIAT (European Myocardial Infarct Amiodarone Trial) and CAMIAT (Canadian Amiodarone Myocardial Infarction Trial) databases. The EMIAT and CAMIAT investigators.
        Circulation. 1999; 99: 2268-2275
        • Thomas K.L.
        • Al-Khatib S.M.
        • Lokhnygina Y.
        • et al.
        Amiodarone use after acute myocardial infarction complicated by heart failure and/or left ventricular dysfunction may be associated with excess mortality.
        Am Heart J. 2008; 155: 87-93
        • Go A.S.
        • Hylek E.M.
        • Borowsky L.H.
        • Phillips K.A.
        • Selby J.V.
        • Singer D.E.
        Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study.
        Ann Intern Med. 1999; 131: 927-934
        • Kowey P.R.
        • Reiffel J.A.
        • Myerburg R.
        • et al.
        Warfarin and aspirin use in atrial fibrillation among practicing cardiologist (from the AFFECTS registry).
        Am J Cardiol. 2010; 105: 1130-1134