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Requests for reprints should be addressed to Gregory Y. H. Lip, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, England.
Department of Cardiology, Cardiovascular Research Centre, Aalborg University Hospital, Aalborg, DenmarkAalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine Aalborg University, Aalborg, Denmark
Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
Department of Cardiology, Cardiovascular Research Centre, Aalborg University Hospital, Aalborg, DenmarkAalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine Aalborg University, Aalborg, Denmark
Department of Cardiology, Cardiovascular Research Centre, Aalborg University Hospital, Aalborg, DenmarkAalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine Aalborg University, Aalborg, Denmark
Current guidelines strongly recommend that oral anticoagulation should be offered to patients with atrial fibrillation and ≥1 stroke risk factors. The guidelines also recommend that oral anticoagulation still should be used in the presence of stroke risk factors irrespective of rate or rhythm control.
Methods
In an analysis from the dataset of the EURObservational Research Programme on Atrial Fibrillation Pilot Survey (n = 3119), we examined antithrombotic therapy prescribing, with particular focus on the risk factors determining oral anticoagulation or antiplatelet therapy use.
Results
When oral anticoagulation was used among admitted patients in whom no pharmacologic cardioversion, electrical cardioversion, or catheter ablation was performed or planned, vitamin K antagonist therapy was prescribed in the majority (72.2%), whereas novel oral anticoagulants were used in the minority (7.7%). There was no significant difference in bleeding risk factors among the patients treated with the different types of antithrombotic therapies, except for those with chronic kidney disease, in whom oral anticoagulation was less commonly used (P = .0318). Antiplatelet therapy was more commonly used in patients with a high Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly score (≥2) (P < .0001). More oral anticoagulation use was associated with female gender (P = .0245). Less novel oral anticoagulant use was associated with valvular heart disease (P < .0001), chronic heart failure (P = .0010), coronary artery disease (P < .0001), and peripheral artery disease (P = .0092). Coronary artery disease was the strongest reason for combination therapy with oral anticoagulation plus antiplatelet drug (odds ratio, 8.54; P < .0001). When the Congestive heart failure, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [female] score was used, 95.6% of patients with a score ≥1 received antithrombotic therapy, with 80.5% of patients with a score ≥1 receiving oral anticoagulation. Of note, 83.7% of those with a score ≥2 received antithrombotic therapy. Of the latter, 70.9% of those with a score ≥2 received oral anticoagulation, vitamin K antagonists were used in 64.1%, and novel oral anticoagulants were used in 6.9%.
Conclusions
The EURObservational Research Programme on Atrial Fibrillation Pilot Survey provides contemporary data on oral anticoagulation prescribing by European cardiologists for atrial fibrillation. Although the uptake of oral anticoagulation (mostly vitamin K antagonist therapy) has improved since the Euro Heart Survey a decade ago, antiplatelet therapy is still commonly prescribed, with or without oral anticoagulation, whereas elderly patients are commonly undertreated with oral anticoagulation.
The EURObservational Research Programme on Atrial Fibrillation (EORP-AF) Pilot Survey provides contemporary data on oral anticoagulation prescribing by European cardiologists.
•
When oral anticoagulation was used, vitamin K antagonists were prescribed in the majority of patients (72.2%). Novel oral anticoagulants were used in the minority (7.7%) of patients. In addition, 80.5% of patients with a Congestive heart failure, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [female] (CHA2DS2-VASc) score ≥1 received oral anticoagulation.
•
Antiplatelet therapy is still overprescribed, with or without oral anticoagulation, whereas elderly patients are commonly undertreated with oral anticoagulation.
Stroke prevention is central to the management of atrial fibrillation.
This common arrhythmia is associated with a high risk of stroke and thromboembolism, and when strokes occur in association with atrial fibrillation, there is greater mortality and morbidity with more disability, longer hospital stays, and a lower rate of discharge to the patient's home.
concluded that antithrombotic therapy in atrial fibrillation was hardly tailored to the patient's stroke risk profile and suggested that factors other than well-known stroke risk factors were significantly involved in antithrombotic management decisions. There was a call that guideline writers and physician educators should focus on providing one uniform and easy to use stroke risk stratification scheme. Since the Euro Heart Survey, the European Society of Cardiology (ESC) has produced new guidelines
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
and introduced use of the Congestive heart failure, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [female]
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.
scores for stroke and bleeding risk stratification, respectively. The availability of novel oral anticoagulants also has changed the landscape for stroke prevention, given their efficacy, safety, and relative convenience.
Of importance, the 2012 focused update of the ESC guidelines strongly recommended a clinical practice shift, so that the initial decision step is the identification of “truly low-risk” patients with atrial fibrillation who do not need any antithrombotic therapy.
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
Subsequent to this step, effective stroke prevention (essentially oral anticoagulation) can be offered to patients with ≥1 stroke risk factors. More recently, similar recommendations from the Asia Pacific Heart Rhythm Society were published.
Also, the ESC guidelines recommended that oral anticoagulation should still be used in the presence of stroke risk factors irrespective of rate or rhythm control and whether the latter was successful.
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
American and Canadian guidelines are broadly similar, recommending oral anticoagulation for patients with stroke risk factors, irrespective of whether a rhythm-control strategy was successful.
Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.
Focused 2012 update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: recommendations for stroke prevention and rate/rhythm control.
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 developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
In this analysis from the baseline dataset of the EURObservational Research Programme on Atrial Fibrillation (EORP-AF) Pilot Survey, we examined antithrombotic therapy prescribing, with particular focus on the risk factors determining oral anticoagulation or antiplatelet therapy use. Furthermore, we assessed the uptake of oral anticoagulation use among patients undergoing rhythm control (cardioversion or ablation).
Materials and Methods
The full baseline features and results from the EORP-AF Pilot Survey have been published.
A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry.
In this ancillary analysis, we focused on the clinical features associated with antithrombotic therapy use. In brief, the registry population comprised consecutive inpatients and outpatients with atrial fibrillation presenting to cardiologists in participating ESC countries. Consecutive patients were screened for eligibility at the time of their presentation to a cardiologist (hospital or medical center). All patients provided written informed consent. Patients with the primary or secondary recorded diagnosis of atrial fibrillation were included.
Patients were officially enrolled in the EORP-AF only if an electrocardiographic diagnosis (12-lead electrocardiogram, 24-hour Holter, or other electrocardiographic documentation) confirming atrial fibrillation was made. The qualifying episode of atrial fibrillation should have occurred within the last year, and patients did not need to be in atrial fibrillation at the time of enrollment. For the pilot phase, 9 countries formally participated. A minimum of 20 consecutive patients per center were to be enrolled, with a target of 3000 patients. Enrollment in the registry started in February 2012, and the end of enrollment was March 2013.
Statistical Analyses
Univariate analysis was applied to both continuous and categoric variables. Continuous variables were reported as mean ± standard deviation or as median and interquartile range. Among-group comparisons were made using a nonparametric test (Kruskal–Wallis test). Categoric variables were reported as percentages. Among-group comparisons were made using a chi-square test or a Fisher exact test if any expected cell count was less than 5.
Results
We enrolled 3119 patients from February 2012 to March 2013. Table 1 shows the characteristics versus antithrombotic drug use of patients admitted to the hospital in whom no pharmacologic or electrical cardioversion and catheter ablation were performed or planned. In the whole cohort, when oral anticoagulation was used, vitamin K antagonist therapy was prescribed in the majority (651/902 = 72.2%), whereas novel oral anticoagulants were used in the minority (69/902 = 7.7%). No antithrombotic therapy was used in 2.7% of patients (24/902).
Table 1Characteristics Versus Antithrombotic Drug Use in Hospitalized Patients with Atrial Fibrillation Where No Pharmacologic Cardioversion, Electrical Cardioversion, or Catheter Ablation Was Performed or Planned
Others include OAC + other antithrombotic therapy, antiplatelet + other antithrombotic therapy, OAC + antiplatelet + other antithrombotic therapy and other antithrombotic therapy (fondaparinux, low-molecular weight heparin, unfractionated heparin, other).
P Value
No.
902
24
482
127
193
76
Reason for visit:
AF (%)
31.60
58.33
34.85
30.71
22.80
26.32
Acute myocardial infarction (%)
8.20
4.17
0.83
16.54
20.73
10.53
Valvular heart disease (%)
7.10
4.17
6.43
6.30
6.74
14.47
Hypertension (%)
1.33
0.00
1.66
0.79
1.04
1.32
<.0001
Heart failure (%)
31.60
20.83
39.42
29.13
18.65
22.37
Other coronary artery disease (%)
8.87
0.00
2.90
9.45
21.24
17.11
Other cardiac (%)
8.54
12.50
11.41
3.94
6.22
2.63
Other noncardiac reason (%)
2.77
0.00
2.49
3.15
2.59
5.26
Demographics:
Age (y) (mean ± SD)
71.16 ± 11.3
61.46 ± 14.6
70.16 ± 11.4
75.27 ± 11.3
71.62 ± 10.4
72.53 ± 9.0
<.0001
Age (y) (median, IQR)
73.0 (64.0-79.0)
64.5 (49.0-72.5)
72.0 (64.0-78.0)
77.0 (67.0-84.0)
72.0 (64.0-79.0)
73.0 (66.0-80.0)
Female gender (%)
41.02
20.83
45.85
44.09
33.68
30.26
.0018
Stroke risk factors:
Valvular heart disease (%)
72.10
57.89
70.26
75.41
74.87
74.67
.3636
Ischemic thromboembolic complications (%)
16.63
4.17
17.12
11.02
20.42
17.33
.1051
Previous TIA (%)
4.81
0.00
4.40
4.72
6.77
4.05
.5425
Previous stroke (%)
7.91
0.00
8.54
6.35
7.25
10.67
.4564
Chronic heart failure (%)
63.37
63.16
68.52
54.76
56.77
62.67
.0014
Hypertension (%)
74.05
54.17
73.28
72.22
76.68
81.58
.0830
Coronary artery disease (%)
47.59
31.25
26.47
61.61
81.87
62.50
<.0001
Peripheral vascular disease (%)
15.01
4.76
12.36
15.20
19.27
22.97
.0305
Diabetes mellitus (%)
26.67
20.83
27.23
19.69
29.26
30.26
.3075
Bleeding risk factors:
Hemorrhagic events (%)
9.15
8.33
8.77
7.20
8.33
17.11
.1578
Malignancy (%)
4.60
8.33
4.17
4.07
4.21
8.11
.5269
Chronic kidney disease (%)
21.62
33.33
19.09
30.71
19.69
23.68
.0318
Type of AF:
First detected (%)
36.49
29.17
37.77
46.83
32.98
21.92
Paroxysmal (%)
19.04
33.33
16.09
20.63
22.34
21.92
Persistent (%)
12.54
16.67
12.02
7.14
13.30
21.92
.0018
Long-standing persistent (%)
2.39
0.00
1.50
4.76
2.13
5.48
Permanent (%)
29.53
20.83
32.62
20.63
29.26
28.77
Heart rhythm strategy:
Rate control only (%)
63.53
45.83
63.69
54.33
65.80
77.63
Rate and rhythm control (%)
24.61
33.33
23.24
30.71
27.98
11.84
.0052
Rhythm control only (%)
5.54
12.50
6.22
8.66
2.59
1.32
Observation (%)
6.32
8.33
6.85
6.30
3.63
9.21
HAS-BLED score:
<.0001
0
13.64
37.5
17.01
7.87
6.74
11.84
1
34.15
20.83
42.74
21.26
26.94
23.68
≥2
52.22
41.67
40.25
70.87
66.32
64.47
AF = atrial fibrillation; HAS-BLED = Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly; IQR = interquartile range; LMW = low-molecular-weight; OAC = oral anticoagulation; SD = standard deviation; TIA = transient ischemic attack; UF = unfractionated.
∗ Others include OAC + other antithrombotic therapy, antiplatelet + other antithrombotic therapy, OAC + antiplatelet + other antithrombotic therapy and other antithrombotic therapy (fondaparinux, low-molecular weight heparin, unfractionated heparin, other).
Oral anticoagulation was commonly prescribed for permanent atrial fibrillation, usually when heart failure (39.4%) or other cardiac diseases were present. Antiplatelet therapy was commonly prescribed, regardless of whether there was coexistent myocardial infarction or coronary artery disease.
The mean age of patients prescribed oral anticoagulation was lower than those prescribed antiplatelet therapy alone (P < .0001). There were similar proportions of female patients who were prescribed both oral anticoagulation and antiplatelet therapy (Table 1). Stroke risk factors were not different between various antithrombotic therapy regimens, apart from heart failure (68.5% receiving oral anticoagulation, P = .0014), coronary artery disease (more antiplatelet therapy, P < .0001), and peripheral artery disease (more antiplatelet therapy, P = .0031).
There was no significant difference in bleeding risk factors between the different types of antithrombotic therapies used, except for chronic kidney disease, for which oral anticoagulation was less commonly used (P = .0318). Antiplatelet therapy was more commonly used in patients with a high HAS-BLED score (≥2) (P < .0001).
Patients with paroxysmal atrial fibrillation were less likely to receive oral anticoagulation than those with permanent atrial fibrillation, although of the latter, more than 60% received oral anticoagulation alone or in combination with antiplatelet therapy (P = .0018). With regard to management strategy, of those undergoing rate control, most received oral anticoagulation alone or in combination with antiplatelet therapy (P = .0052). Of those receiving oral anticoagulation alone, vitamin K antagonists were used in 90.4% of patients (651/720) and novel oral anticoagulants were used in 9.6% of patients (69/720). Among those receiving combination oral anticoagulation plus antiplatelet therapy, the oral anticoagulant used was a vitamin K antagonist in 92.7% of patients (179/193) and novel oral anticoagulants were used in 7.8% of patients (15/193).
Factors Associated with Oral Anticoagulation Prescription
Factors associated with oral anticoagulation prescription are shown in Tables 2 to 5. More oral anticoagulation use was associated with female gender (P = .0245). Less oral anticoagulation use was associated with valvular heart disease, heart failure, coronary or peripheral artery disease (P < .0001), diabetes mellitus (P = .0012), and subtype of atrial fibrillation (P = .0474) (Table 2).
Table 2Factors Associated with Prescription of Oral Anticoagulation Alone (Vitamin K Antagonists Plus Novel Oral Anticoagulant)
Odds Ratio
95% Confidence Limits
P Value
Age (%), (reference, <65 y)
0.9211
0.7942
1.0683
.2773
Female gender (%)
1.1813
1.0216
1.3661
.0245
Valvular heart disease (%)
0.6592
0.5645
0.7697
<.0001
Previous TIA/stroke (%)
1.2558
0.9788
1.6111
.0728
Chronic heart failure (%)
0.6343
0.5477
0.7345
<.0001
Hypertension (%)
0.9815
0.8393
1.1479
.8153
Coronary artery disease (%)
0.1781
0.1500
0.2114
<.0001
Peripheral vascular disease (%)
0.5505
0.4367
0.6939
<.0001
Diabetes mellitus (%)
0.7488
0.6286
0.8919
.0012
Type of AF (%), (reference, first detected)
0.8549
0.7321
0.9983
.0474
Heart rhythm strategy (%), (reference, rhythm control only)
1.1779
0.9516
1.4581
.1323
AF = atrial fibrillation; TIA = transient ischemic attack.
Factors Associated with Antiplatelet Drug Prescription
Factors associated with antiplatelet drug prescription are shown in Table 4. More antiplatelet drug use was associated with female gender (P = .0428), coronary artery disease (P < .0001), and type of atrial fibrillation (P = .0004), with less use in previous stroke/transient ischemic attack (P = .0123) and diabetes (P = .0426) (Table 4).
Table 4Factors Associated with Prescription of Antiplatelet Drugs Alone
Odds Ratio
95% Confidence Limits
P Value
Age (%), (reference <65 y)
1.0643
0.8545
1.3256
.5781
Female gender (%)
1.2433
1.0068
1.5353
.0428
Valvular heart disease (%)
1.0511
0.8374
1.3192
.6674
Previous TIA/stroke (%)
0.5798
0.3766
0.8927
.0123
Chronic heart failure (%)
0.8658
0.6974
1.0749
.1916
Hypertension (%)
0.9752
0.7749
1.2271
.8301
Coronary artery disease (%)
1.7052
1.3578
2.1414
<.0001
Peripheral vascular disease (%)
0.8938
0.6304
1.2672
.5283
Diabetes mellitus (%)
0.7505
0.5683
0.9913
.0426
Type of AF (%) (reference = first detected)
1.4784
1.1878
1.8401
.0004
Heart rhythm strategy (%), (reference = rhythm control only)
1.2820
0.9576
1.7162
.0944
AF = atrial fibrillation; TIA = transient ischemic attack.
Factors Associated with Oral Anticoagulation Plus Antiplatelet Drug Prescription
Factors associated with combination oral anticoagulation plus antiplatelet drug prescriptions are shown in Table 5. More combination therapy with oral anticoagulation plus antiplatelet drug use was associated with age, valvular heart disease, chronic heart failure, hypertension, coronary and peripheral artery disease, and diabetes (all P < .0001). Coronary artery disease was the strongest reason for combination therapy (odds ratio, 8.54; P < .0001) (Table 5). There was less combination therapy with oral anticoagulation plus antiplatelet drug use in female patients (P = .0002), previous stroke/transient ischemic attack (P = .0159), and heart rhythm strategy (P = .0004).
Table 5Factors Associated with Prescription of Oral Anticoagulation in Combination with Antiplatelet Drugs
Odds Ratio
95% Confidence Limits
P Value
Age (%), (reference age <65 y)
1.5873
1.3031
1.9334
<.0001
Female gender (%)
0.7000
0.5798
0.8450
.0002
Valvular heart disease (%)
1.9615
1.5957
2.4111
<.0001
Previous TIA/stroke (%)
0.5798
0.3766
0.8927
.0159
Chronic heart failure (%)
2.3415
1.9411
2.8246
<.0001
Hypertension (%)
1.8098
1.4553
2.2508
<.0001
Coronary artery disease (%)
8.5486
6.8823
10.6182
<.0001
Peripheral vascular disease (%)
2.5063
1.9551
3.2129
<.0001
Diabetes mellitus (%)
1.8228
1.4855
2.2368
<.0001
Type of AF (%) (reference = first detected)
0.8547
0.6993
1.0447
.1251
Heart rhythm strategy (%) (reference = rhythm control only)
0.5789
0.4253
0.7879
.0004
AF = atrial fibrillation; TIA = transient ischemic attack.
In the whole cohort, the most common risk factors for stroke were heart failure (47.5%) and hypertension (29.3%). Among the anticoagulated cohort, the most common stroke risk factor was hypertension (70.5%) (Table 6).
Table 6Prevalence of Risk Factors for Stroke in Patients According to European Society of Cardiology Guidelines
Whole Cohort
OAC Alone
N
%
N
%
Heart failure (%)
1411
47.48
739
42.74
Hypertension (%)
909
29.29
1262
70.54
Age (%):
<65 y
1030
33.02
613
34.04
65-74 y
1038
33.28
631
35.04
≥75 y
1051
33.70
557
30.93
Diabetes mellitus (%)
638
20.57
333
18.56
Previous TIA (%)
126
4.09
81
4.53
Previous stroke (%)
195
6.30
120
6.68
Ischemic thromboembolic complications (%)
405
13.09
250
13.94
Peripheral vascular disease (%)
328
11.03
143
8.47
Myocardial infarction (%)
439
16.33
113
7.30
Female (%)
1260
40.40
758
42.09
OAC = oral anticoagulation; TIA = transient ischemic attack.
Antithrombotic Therapy Use Based on CHADS2 and CHA2DS2-VASc Scores
On the basis of the Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke [Doubled] (CHADS2) score, 89.3% of those with a score ≥1 received antithrombotic therapy; of these, 75.7% (2243/2964) of those with a score ≥1 received oral anticoagulation: Vitamin K antagonists were used in 68.1% of patients (2019/2964), and novel oral anticoagulants were used in 7.7% of patients (228/2964).
When the CHA2DS2-VASc score was used, 95.6% with a score ≥1 received antithrombotic therapy, with 80.5% (2386/2964) with a score ≥1 receiving oral anticoagulation. Of note, 83.7% of those with a score ≥2 received anti-thrombotic therapy; of the latter, 70.9% (2101/2964) of those with a score ≥2 received oral anticoagulation. Of the latter anticoagulated patients with a CHA2DS2-VASc score ≥2, vitamin K antagonists were used in 64.1% (1900/2964) and novel oral anticoagulants were used in 6.9% (204/2964).
Antithrombotic Therapy Use Based on Rhythm Control
Pharmacologic and electrical cardioversion were planned or performed in 763 and 703 subjects, respectively, whereas catheter ablation was performed or planned in 231 subjects. The clinical characteristics of these patients are summarized in Supplementary Table 1.
For patients in whom pharmacologic cardioversion was performed or planned (n = 763), oral anticoagulation was used in the majority (at least 66.6% at discharge in those in whom pharmacologic cardioversion was performed, or at least 92.3% when planned). No antiplatelet therapy was used when oral anticoagulation was planned (Table 7, Figure 1). In patients undergoing pharmacologic cardioversion who received oral anticoagulation, vitamin K antagonist therapy was prescribed in the majority (92.1%, 477/518 at discharge), whereas novel oral anticoagulants were used in the minority (8.1%, 42/518 at discharge). (One patient received both vitamin K antagonist and novel oral anticoagulants, so n = 477 + 42 does not = 518.) No antithrombotic therapy was used (or status unknown) in 9.1% of patients.
Table 7Antithrombotic Prescription at Inclusion and at Discharge When the Following Pharmacologic Cardioversion Was Performed at the Time of Survey or Planned at Discharge
Others include OAC + other antithrombotic therapy, antiplatelet + other antithrombotic therapy, OAC + antiplatelet + other antithrombotic therapy and other antithrombotic therapy (fondaparinux, low-molecular weight heparin, unfractionated heparin, other).
20
2.7
35
4.7
0
0
0
7.7
Total
750
100.0
750
100.0
13
100.0
3
100.0
Vitamin K Antagonists or Novel Oral Anticoagulation Use
Figure 1Antithrombotic drug prescription at inclusion and discharge when the following interventions were performed at the time of the survey or planned at discharge: pharmacologic cardioversion (A), electrical cardioversion (B), or catheter ablation (C). AP = antiplatelet; OAC = oral anticoagulation.
For patients in whom electrical cardioversion was performed or planned (n = 703), oral anticoagulation was used in the majority (at least 85.5% at discharge in those in whom electrical cardioversion performed, or at least 90.2% when planned). No antiplatelet therapy was used when oral anticoagulation was planned (Table 8, Figure 1). In patients undergoing electrical cardioversion who received oral anticoagulation, vitamin K antagonist therapy was prescribed in the majority (86.3%, 466/540 at discharge), whereas novel oral anticoagulants were used in the minority (13.7%, 74/540 at discharge). No antithrombotic therapy was used (or status unknown) in 4.9% of patients.
Table 8Antithrombotic Prescription at Inclusion and at Discharge When the Following Electrical Cardioversion Was Performed at the Time of Survey or Planned at Discharge
Others include OAC + other antithrombotic therapy, antiplatelet + other antithrombotic therapy, OAC + antiplatelet + other antithrombotic therapy and other antithrombotic therapy (fondaparinux, low-molecular-weight heparin, unfractionated heparin, other).
∗ Others include OAC + other antithrombotic therapy, antiplatelet + other antithrombotic therapy, OAC + antiplatelet + other antithrombotic therapy and other antithrombotic therapy (fondaparinux, low-molecular-weight heparin, unfractionated heparin, other).
† Others include OAC + other antithrombotic therapy and OAC + antiplatelet + other antithrombotic therapy.
Among patients in whom catheter ablation was performed or planned, oral anticoagulation was used in the majority (at least 88.1% at discharge among those in whom ablation performed, or at least 73.3% when planned) (Table 9). In the patients who underwent ablation and received oral anticoagulation, vitamin K antagonist therapy was prescribed in the majority (88.1%, 148/168 at discharge), whereas novel oral anticoagulants were used in the minority (11.9%, 20/168 at discharge). No antithrombotic therapy was used in 7.1% (2.7% performed and 4.4% planned).
Table 9Antithrombotic Prescription at Inclusion and at Discharge When the Following Catheter Ablation Was Performed at the Time of Survey or Planned at Discharge
Others include OAC + other antithrombotic therapy, antiplatelet + other antithrombotic therapy, OAC + antiplatelet + other antithrombotic therapy and other antithrombotic therapy (fondaparinux, low-molecular weight heparin, unfractionated heparin, other).
In this report from the EORP-AF Pilot Survey, we found that oral anticoagulation often was used for atrial fibrillation, especially when heart failure or other cardiac diseases were present. However, antiplatelet therapy still was prescribed routinely with or without oral anticoagulation when there was coexistent myocardial infarction or coronary artery disease. Oral anticoagulation was prescribed less often in elderly patients, and antiplatelet therapy alone was prescribed more commonly. When the CHA2DS2-VASc score was used, 95.58% of patients with a score ≥1 received oral anticoagulation.
Often, oral anticoagulation was used for atrial fibrillation, usually when clinical heart failure or other cardiac disease was present. A clinical diagnosis of heart failure was not an independent predictor for stroke in the systematic review from the Stroke in Atrial Fibrillation Working Group
Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study.
The “C” in CHA2DS2-VASc has been defined as referring to the presence of moderate-severe systolic impairment or recent decompensation irrespective of ejection fraction, given that such patients are still at high risk of thromboembolism.
Often, antiplatelet therapy was prescribed with or without oral anticoagulation when there was coexistent myocardial infarction or coronary artery disease. Antiplatelet monotherapy also was prescribed regularly in such patients. The presence of vascular disease independently increases the risk of stroke in atrial fibrillation.
Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study.
The impact of atherosclerotic vascular disease in predicting a stroke, thromboembolism and mortality in atrial fibrillation patients: a systematic review.
Thus, in patients with atrial fibrillation with stable vascular disease, oral anticoagulation is the preferred treatment option, because combination therapy does not reduce thromboembolism but substantially increases the risk of major bleeding, especially intracranial hemorrhage.
The situation is complex in patients with atrial fibrillation presenting with an acute coronary syndrome or undergoing angioplasty or stenting, with guidelines recommending a period of triple therapy, followed by oral anticoagulation plus single antiplatelet, and then oral anticoagulation alone.
Recent data from a small randomized trial and a nationwide cohort study suggest that oral anticoagulation plus clopidogrel would be sufficient for post–acute coronary syndrome treated with coronary stenting.
Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial.
Bleeding risk factors were similar between the different types of antithrombotic therapies used, except when oral anticoagulation was less commonly used in chronic kidney disease.
Patients with chronic kidney disease and atrial fibrillation are at higher risk of thromboembolism, myocardial infarction, and death, as well as major bleeding.
As in the original Euro Heart Survey, oral anticoagulation was used less often in paroxysmal atrial fibrillation, although such patients remain at high risk of thromboembolism.
Indeed, guidelines emphasize that in the presence of stroke risk factors, oral anticoagulation should be prescribed irrespective of the clinical type of atrial fibrillation (paroxysmal, persistent, permanent).
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
There was a tendency for oral anticoagulation to be prescribed less in younger patients and for antiplatelet therapy alone to be prescribed more in the elderly. In the trials with elderly patients, oral anticoagulation was associated with a significant reduction in thromboembolism, and the risks of major bleeding or adverse effects were similar or higher with aspirin compared with warfarin in the elderly.
Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial.
Antiplatelet therapy was used more often in patients with a high HAS-BLED score, perhaps because of the perception that aspirin was a safer alternative than oral anticoagulants. The evidence is clear that the risk of major bleeding (or intracranial bleeding) with aspirin is not significantly different than with oral anticoagulation, especially in the elderly.
Thus, recent treatment guidelines from Europe and North America have downgraded the role of aspirin for stroke prevention in atrial fibrillation, given its limited (or lack of) efficacy and poor safety.
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.
In the whole cohort, the most common risk factors for stroke were heart failure and hypertension. This is in keeping with various epidemiologic datasets or surveys in which heart failure and hypertension were the most common etiologic factors for atrial fibrillation and contributed to its thromboembolic complications.
Oral anticoagulation use by patients with atrial fibrillation in Germany. Adherence to guidelines, causes of anticoagulation under-use and its clinical outcomes, based on claims-data of 183,448 patients.
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).
On the basis of the CHADS2 score, 89.34% of patients with a score ≥1 received oral anticoagulation. When the CHA2DS2-VASc score was used, 95.58% with a score ≥1 received oral anticoagulation, and 83.67% of those with a score ≥2 received oral anticoagulation. This is an improvement over reported data in the Euro Heart Survey,
with an increase of oral anticoagulation use among cardiologists. Indeed, this may reflect the introduction of new guidelines. In the 2012 focused update of the ESC guideline, the initial decision step is to identify “low-risk” patients who did not require any antithrombotic therapy (ie, aged <65 years and lone atrial fibrillation; otherwise a CHA2DS2-VASc score = 0 [male] or CHA2DS2-VASc score = 1 [female]).
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
Subsequent to this step, patients with ≥1 stroke risk factors can be offered effective stroke prevention, which is oral anticoagulation, whether given as well-controlled vitamin K antagonist therapy (with a long time in the therapeutic range, >70%
Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis - Task Force on Anticoagulants in Heart Disease.
Despite a preference for the use of novel oral anticoagulants in the ESC guidelines, they were prescribed in the minority, but this survey shows their use particularly in patients with previous transient ischemic attack/stroke or rhythm control. Novel oral anticoagulants were used less in association with valvular heart disease, heart failure, and vascular disease; the latter may be due to concerns, particularly with dabigatran, in patients with associated coronary artery disease.
Wider use of novel oral anticoagulants would have implications for improved stroke-prevention outcomes in Europe, given their relative efficacy, safety, and convenience compared with vitamin K antagonists, which ultimately lead to a greater net clinical benefit overall.
Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: a modelling analysis based on a nationwide cohort study.
Potential net clinical benefit of population-wide implementation of apixaban and dabigatran among European patients with atrial fibrillation. A modelling analysis from the Euro Heart Survey.
In addition, not all the novel oral anticoagulants were available in some participating countries at the time of data collection.
Oral anticoagulation also is needed in the setting of rhythm-control therapy. Pharmacologic and electrical cardioversion were planned or performed in 763 and 703 subjects, respectively, whereas catheter ablation and oral anticoagulation were used in the majority. The proportion in whom oral anticoagulation was not used could be explained by the proportion of patients with new-onset atrial fibrillation in whom oral anticoagulation is not initiated in some countries when early conversion to sinus rhythm is achieved. Nonetheless, the ESC guidelines do recommend that oral anticoagulation should be used in the presence of stroke risk factors, irrespective of whether a successful rhythm-control strategy (ie, cardioversion or ablation) is achieved.
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
We did not have data on the quality of anticoagulation control or on the time in therapeutic range, which is highly relevant given that the latter is a major determinant of thromboembolism, bleeding, and death in patients treated with vitamin K antagonists.
Also, we did not have detailed data on biochemical parameters or outcomes, which will be addressed by the ongoing follow-up phase of the EORP-AF Pilot, to be reported in late 2014.
Conclusions
The EORP-AF Pilot Survey provides contemporary data on oral anticoagulation prescribing by European cardiologists for atrial fibrillation. Although the uptake of oral anticoagulation (mostly vitamin K antagonist therapy) has improved since the Euro Heart Survey a decade ago, antiplatelet therapy still is prescribed routinely with or without oral anticoagulation, whereas elderly patients often are undertreated with oral anticoagulation.
Acknowledgments
Executive steering committee, Steering Committee (National Coordinators), and Study Investigators were listed in the primary article describing the baseline data, by Lip et al.
A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry.
Data monitor and technical support team: Data collection was conducted by the EURObservational Research Program department from the European Cardiac Society by Viviane Missiamenou. Statistical analyses were performed by Cécile Laroche with the support of Renato Urso. Overall activities were coordinated by Aldo P. Maggioni (Scientific Coordinator, EORP) and Thierry Ferreira (Head of Department, EORP).
Appendix
Supplementary Table 1Characteristics of Patients in Whom an Intervention to Restore Sinus Rhythm Was Performed or Planned
Pharmacologic Cardioversion
Electrical Cardioversion
Catheter Ablation
N = 763
N = 703
N = 231
Performed
Planned
Performed
Planned
Performed
Planned
N = 750
N = 13
N = 612
N = 91
N = 186
N = 45
Demographics:
Age (y) (mean ± SD)
67.9 ± 11.7
68.2 ± 9.2
66.0 ± 11.3
64.2 ± 9.8
59.4 ± 10.8
62.9 ± 9.0
Age (y) (median, IQR)
69.0 (61.0-76.0)
65.0 (63.0-74.0)
67.0 (59.0-74.0)
64.0 (59.0-71.0)
61.0 (53.0-67.0)
62.0 (57.0-70.0)
Female gender (%)
46.27
30.77
34.31
28.57
35.48
40.00
Duration of current AF episode (%):
<24 h
40.40
15.38
22.71
5.49
30.11
26.67
24 h to 7 d
18.67
7.69
14.54
19.78
8.60
15.56
>7 d
27.87
53.85
48.37
63.74
25.81
33.33
Unknown
13.07
23.08
14.38
10.99
35.48
24.44
CHA2DS2-VASc (%):
0 (all) and 1 (female)
8.93
15.38
11.60
9.89
27.42
17.78
1 (male)
8.53
15.38
18.46
26.37
24.19
6.67
2 and more (all)
82.53
69.23
69.93
63.74
48.39
75.56
AF = atrial fibrillation; CHA2DS2-VASc = Congestive heart failure, Hypertension, Age ≥75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [female]; IQR = interquartile range; SD = standard deviation.
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation–developed with the special contribution of the European Heart Rhythm Association.
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.
Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.
Focused 2012 update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: recommendations for stroke prevention and rate/rhythm control.
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 developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry.
Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study.
The impact of atherosclerotic vascular disease in predicting a stroke, thromboembolism and mortality in atrial fibrillation patients: a systematic review.
Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial.
Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial.
Oral anticoagulation use by patients with atrial fibrillation in Germany. Adherence to guidelines, causes of anticoagulation under-use and its clinical outcomes, based on claims-data of 183,448 patients.
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).
Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis - Task Force on Anticoagulants in Heart Disease.
Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: a modelling analysis based on a nationwide cohort study.
Potential net clinical benefit of population-wide implementation of apixaban and dabigatran among European patients with atrial fibrillation. A modelling analysis from the Euro Heart Survey.
Conflict of Interest: GYHL is a consultant for Bayer, Medtronic, Sanofi, BMS/Pfizer, Daiichi-Sankyo, and Boehringer Ingelheim, and has been a speaker for Bayer, BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, and Medtronic. LHR is on the speakers bureaus for Bayer, BMS/Pfizer, Janssen Pharmaceuticals, Takeda, Roche Diagnostics, and Boehringer Ingelheim. GB has received small speaker's fees from Medtronic Inc and Boston Scientific. The remaining authors do not have any conflicts of interest associated with the work presented in this manuscript. EURObservational Research Programme Sponsors: At the time of the registry, the following companies were supporting the EURObservational Research Programme: GOLD: Abbott Vascular, Bayer Pharma, Bristol Myers Squibb (BMS), Pfizer, Boehringer Ingelheim, Daiichi Sankyo Europe, Menarini International Operations, Novartis Pharma, Sanofi-Aventis, Servier International. SILVER: Amgen. BRONZE: Boston Scientific International, Merck & Co (MSD).
Authorship: All authors had access to the data and played a role in writing this manuscript.
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