AF mortality and morbidity high at one year despite good anticoagulant use
Mortality and morbidity of atrial fibrillation (AF) patients remains high at one year despite good use of oral anticoagulants, according to the one year follow up of the Atrial Fibrillation General Pilot Registry. The findings were presented for the first time at ESC Congress 2014 today by registry chairperson Professor Gregory Lip (Birmingham, UK).
Professor Lip said: "This is the first contemporary, ESC sponsored registry focused on management practices of European cardiologists conducted since the ESC guidelines on AF were published in 2010 and 2012(1,2). The results show us the impact of these ESC guidelines."
The Atrial Fibrillation General Pilot Registry is part of the ESC's EORP programme and includes over 3 000 patients in 9 countries. Data are being collected on treatment and outcomes of consecutive patients with AF presenting to European cardiologists.
The one year follow up results reveal that more than 80% of AF patients who are at risk of embolism according to the CHA2DS2-VASc score receive appropriate anticoagulation. But one year mortality is still high (approximately 6%), of which most are cardiovascular deaths. Approximately 20% of patients taking anticoagulants required a change in treatment at one year. Some patients taking warfarin switched to a non-vitamin K antagonist oral anticoagulant (NOAC), while some initially on a NOAC changed to a different antithrombotic drug. A small minority were started on aspirin despite the guidelines and little evidence for the efficacy and safety of aspirin.
Professor Lip said: "The results show that many European cardiologists prescribe oral anticoagulation for their patients with AF and this is encouraging. But we shouldn't rest on our laurels given that these patients still experience high mortality and morbidity at one year. And we need more information on why so many patients are changing the type of anticoagulation they use."
The researchers compared which risk factors present at baseline predicted stroke or mortality at one year. They found that the main predictors of stroke or mortality were age, heart failure, previous transient ischaemic attack (TIA), kidney disease, malignancy and previous bleeding events. The highest predictors of mortality alone were kidney disease, diuretic use, age, malignancy, previous TIA, previous bleeding and chronic obstructive pulmonary disease (COPD). Statins were protective against mortality.
Professor Lip said: "Interestingly, we found that statins reduced mortality by about one-third. On the other hand, diuretics increased mortality by about 70%."
Other findings from the one year follow up were:
- Many patients with AF are frequently asymptomatic, but symptoms are still very common amongst some AF patients
- Patients classed as low risk using the CHA2DS2-VASc score had a low mortality and a low morbidity
- Hospital readmissions were very common and were often due to AF or heart failure.
Professor Lip concluded: "These one year results are generally encouraging and uptake of ESC guidelines has been reasonably good. There has been a focus on patient centred and symptom directed management, and there has been an improvement in anticoagulation with increasing use of the CHA2DS2-VASc score. However we still need to pay attention to the high mortality and morbidity of AF patients and the tendency of some cardiologists to change the type of anticoagulation after one year."
The Atrial Fibrillation General Pilot Registry is ongoing and further results will be reported at years two and three. The Atrial Fibrillation General Long Term Registry began in October 2013 and is currently recruiting from ESC member countries.
(1) Guidelines for the management of atrial fibrillation. European Heart Journal (2010) 31, 2369 DOI: 10.1093/eurheartj/ehq278
(2) 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal (2012) 33, 2719 DOI: 10.1093/eurheartj/ehs253