MAIN SESSION
Insights into the management of atrial
fibrillation in clinical practice in Europe: results of the Euro Heart Survey on atrial fibrillation Stockholm, 5 September 2005 In this main session the results of the Euro Heart Survey on atrial fibrillation were presented. The session was chaired by S. Cobbe (Glasgow, UK) and J. Daubert (Rennes, France). The Euro Heart Survey on atrial fibrillation was conducted in 182 centres in 35 countries in 2004. The study population comprised 5330 patients with atrial fibrillation (AF). Using a questionnaire with more than 200 questions, data were collected on characteristics, management and outcome of consecutive patients with AF.
antiarrhythmic drugs are more often prescribed. Finally, no significant difference in mortality was observed between patients with symptomatic and asymptomatic AF. In conclusion, a large proportion of symptomatic patients become asymptomatic at one-year follow-up. Patients with asymptomatic AF are more frequently treated with rate control, and no differences in outcome were observed between symptomatic and asymptomatic patients.
The first speaker was S. Olssen (Lund, Sweden). He focused on the question whether there are differences in characteristics, treatment and outcome of patients with symptomatic or asymptomatic AF. In different guidelines various definitions ofasymptomatic AF are used. In this Euro Heart Survey, asymptomatic AF was defined as 'no current symptoms of AF'. If a patient was asymptomatic at the time of enrolment, previous symptomatic episodes had to be reported. The majority of patients (3680 of 5330, 70%) were symptomatic at entrance. The most frequently reported symptoms were palpitations (49.9%), dyspnoea (31.0%) and fatigue (27.0%). The proportion of symptomatic patients was largest among patients with paroxysmal AF. Accordingly, patients with persistent or permanent AF were more frequently asymptomatic. At one-year follow-up the presence ofsymptoms was reassessed. A decrease in the percentage of symptomatic patients was observed. About 50% ofthe symptomatic patients were asymptomatic at one-year follow-up. A different drug strategy for symptomatic and asymptomatic patients was observed. In asymptomatic patients the most common treatment strategy is rate control, whereas in patients with symptomatic AF
The second speaker, F. Follath (Zurich, Switzerland), discussed the relation between AF and heart failure in this Euro Heart Survey. At baseline 35% of the patients had heart failure, the majority were in NYHA (New York Heart Association) class II or III. Similar to the findings of the Euro Heart Survey on heart failure, persistent AF, permanent AF and a higher age were associated with the presence of heart failure. Furthermore, valvular disease and coronary artery disease were more often present in patients with heart failure compared with those without. Among patients with AF and heart failure, drug regime differed based on LVEF and functional class. Consistent with the findings in the Euro Heart Survey on heart failure, patients with heart failure and left ventricular ejection fraction 70 years and patients with heart failure. Furthermore, electrical cardioversion was mainly performed in patients with persistent AF, while pharmacological cardioversion was performed in patients with paroxysmal or first detected AF. The speaker concluded that there is a large variation in methods used for both pharmacological and electrical cardioversion. For pharmacological cardioversion non-recommended drugs seem effective to some extent and the effectiveness of biphasic shocks for electrical cardioversion was confirmed in this study.
The fourth speaker was H. Crijns (Maastricht, the Netherlands), chair of the Euro Heart Survey on atrial fibrillation. Since patients with AF have an increased risk for thromboembolic events, anticoagulant therapy is recommended by the different guidelines. According to the risk stratification schemes ofthe ACC/AHA/ESC and CHADS2, the majority ofthe patients enrolled in the Euro Heart Survey were categorised as high-risk patients. However, the percentage of patients receiving anticoagulant therapy was similar in low-risk and highrisk patients. Apparently, anticoagulant therapy was not driven by the risk for thromboembolic events. Furthermore, changes in anticoagulant strategy were studied. The majority ofthe patients taking anticoagulants at baseline were still on oral anticoagulants at one-year follow-up. In contrast, 50% ofthe patients who received oral anticoagulants and antiplatelet therapy at enrolment received only anticoagulants at
qC
Netherlands Heart Joumal, Volume 13, Supplement 2, November 2005
one-year follow-up. Determinants ofthe use oforal anticoagulants were persistent or permanent AF, valvular disease, diabetes, and prior stroke/TIA. In contrast, age >75 years decreased the chance of receiving oral anticoagulants. Finally, the outcome ofpatients was studied in relation to the anticoagulant strategy. Patients receiving oral anticoagulants had a lower chance of reaching the combined endpoint (mortality, stroke/TIA, new onset heart failure or worsening of existing heart failure) during one-year follow-up as compared with patients not receiving oral anticoagulants (OR 0.70, 95% CI 0.57 to 0.85, p=0.000). The speaker concluded that risk schemes are not well applied in daily practice. Especially older patients are undertreated and outcome of patients with AF can be improved by choosing the right anticoagulant strategy.
Finally, A. Capucci (Piacenza, Italy) discussed rhythm control in patients with paroxysmal versus persistent AF. In total 77% of the patients with paroxysmal or persistent AF were under rhythm control. More patients with persistent AF received amiodarone compared with patients with paroxysmal AF. Furthermore, a change in rate or rhythm control strategy was observed during follow-up. In patients with paroxysmal AF, 15% changed from rhythm to rate control, whereas 30% changed from rate to rhythm control. In patients with persistent AF the same trend was observed: 15% changed from rhythm to rate control, and 35% ofthe patients changed from rate to rhythm control. A multivariate analysis ofthe outcome revealed that patients with a rate control strategy had a lower change ofreaching the combined endpoint (mortality, stroke/ TIA, major bleeding or heart failure) compared with patients with rhythm control strategy. However, this difference was not statistically different (OR0.80, 95% CI 0.64 to 1.00, p=0.05). The speaker concluded that in daily practice a rhythm control strategy is preferred in both paroxysmal and persistent AF; however, this strategy may change during follow-up in both groups. In conclusion, the Euro Heart Survey on atrial fibrillation has provided insight in the characteristics, management and outcome of patients with AF in Europe. As expected, heart failure and AF are frequently associated. Differences in rhythm or rate control strategy among the different AF patients are observed. Furthermore, both pharmacological and electrical cardioversion are widely applied in various forms. Finally, anticoagulant strategy needs more attention, especially in high-risk patients. Further analysis of the data in the Euro Heart Survey on atrial fibrillation may provide additional information on treatment and outcome of patients with AF. -
17
Insights into the management of atrial
fibrillation in clinical practice in Europe: results of the Euro Heart Survey on atrial fibrillation Stockholm, 5 September 2005 In this main session the results of the Euro Heart Survey on atrial fibrillation were presented. The session was chaired by S. Cobbe (Glasgow, UK) and J. Daubert (Rennes, France). The Euro Heart Survey on atrial fibrillation was conducted in 182 centres in 35 countries in 2004. The study population comprised 5330 patients with atrial fibrillation (AF). Using a questionnaire with more than 200 questions, data were collected on characteristics, management and outcome of consecutive patients with AF.
antiarrhythmic drugs are more often prescribed. Finally, no significant difference in mortality was observed between patients with symptomatic and asymptomatic AF. In conclusion, a large proportion of symptomatic patients become asymptomatic at one-year follow-up. Patients with asymptomatic AF are more frequently treated with rate control, and no differences in outcome were observed between symptomatic and asymptomatic patients.
The first speaker was S. Olssen (Lund, Sweden). He focused on the question whether there are differences in characteristics, treatment and outcome of patients with symptomatic or asymptomatic AF. In different guidelines various definitions ofasymptomatic AF are used. In this Euro Heart Survey, asymptomatic AF was defined as 'no current symptoms of AF'. If a patient was asymptomatic at the time of enrolment, previous symptomatic episodes had to be reported. The majority of patients (3680 of 5330, 70%) were symptomatic at entrance. The most frequently reported symptoms were palpitations (49.9%), dyspnoea (31.0%) and fatigue (27.0%). The proportion of symptomatic patients was largest among patients with paroxysmal AF. Accordingly, patients with persistent or permanent AF were more frequently asymptomatic. At one-year follow-up the presence ofsymptoms was reassessed. A decrease in the percentage of symptomatic patients was observed. About 50% ofthe symptomatic patients were asymptomatic at one-year follow-up. A different drug strategy for symptomatic and asymptomatic patients was observed. In asymptomatic patients the most common treatment strategy is rate control, whereas in patients with symptomatic AF
The second speaker, F. Follath (Zurich, Switzerland), discussed the relation between AF and heart failure in this Euro Heart Survey. At baseline 35% of the patients had heart failure, the majority were in NYHA (New York Heart Association) class II or III. Similar to the findings of the Euro Heart Survey on heart failure, persistent AF, permanent AF and a higher age were associated with the presence of heart failure. Furthermore, valvular disease and coronary artery disease were more often present in patients with heart failure compared with those without. Among patients with AF and heart failure, drug regime differed based on LVEF and functional class. Consistent with the findings in the Euro Heart Survey on heart failure, patients with heart failure and left ventricular ejection fraction 70 years and patients with heart failure. Furthermore, electrical cardioversion was mainly performed in patients with persistent AF, while pharmacological cardioversion was performed in patients with paroxysmal or first detected AF. The speaker concluded that there is a large variation in methods used for both pharmacological and electrical cardioversion. For pharmacological cardioversion non-recommended drugs seem effective to some extent and the effectiveness of biphasic shocks for electrical cardioversion was confirmed in this study.
The fourth speaker was H. Crijns (Maastricht, the Netherlands), chair of the Euro Heart Survey on atrial fibrillation. Since patients with AF have an increased risk for thromboembolic events, anticoagulant therapy is recommended by the different guidelines. According to the risk stratification schemes ofthe ACC/AHA/ESC and CHADS2, the majority ofthe patients enrolled in the Euro Heart Survey were categorised as high-risk patients. However, the percentage of patients receiving anticoagulant therapy was similar in low-risk and highrisk patients. Apparently, anticoagulant therapy was not driven by the risk for thromboembolic events. Furthermore, changes in anticoagulant strategy were studied. The majority ofthe patients taking anticoagulants at baseline were still on oral anticoagulants at one-year follow-up. In contrast, 50% ofthe patients who received oral anticoagulants and antiplatelet therapy at enrolment received only anticoagulants at
qC
Netherlands Heart Joumal, Volume 13, Supplement 2, November 2005
one-year follow-up. Determinants ofthe use oforal anticoagulants were persistent or permanent AF, valvular disease, diabetes, and prior stroke/TIA. In contrast, age >75 years decreased the chance of receiving oral anticoagulants. Finally, the outcome ofpatients was studied in relation to the anticoagulant strategy. Patients receiving oral anticoagulants had a lower chance of reaching the combined endpoint (mortality, stroke/TIA, new onset heart failure or worsening of existing heart failure) during one-year follow-up as compared with patients not receiving oral anticoagulants (OR 0.70, 95% CI 0.57 to 0.85, p=0.000). The speaker concluded that risk schemes are not well applied in daily practice. Especially older patients are undertreated and outcome of patients with AF can be improved by choosing the right anticoagulant strategy.
Finally, A. Capucci (Piacenza, Italy) discussed rhythm control in patients with paroxysmal versus persistent AF. In total 77% of the patients with paroxysmal or persistent AF were under rhythm control. More patients with persistent AF received amiodarone compared with patients with paroxysmal AF. Furthermore, a change in rate or rhythm control strategy was observed during follow-up. In patients with paroxysmal AF, 15% changed from rhythm to rate control, whereas 30% changed from rate to rhythm control. In patients with persistent AF the same trend was observed: 15% changed from rhythm to rate control, and 35% ofthe patients changed from rate to rhythm control. A multivariate analysis ofthe outcome revealed that patients with a rate control strategy had a lower change ofreaching the combined endpoint (mortality, stroke/ TIA, major bleeding or heart failure) compared with patients with rhythm control strategy. However, this difference was not statistically different (OR0.80, 95% CI 0.64 to 1.00, p=0.05). The speaker concluded that in daily practice a rhythm control strategy is preferred in both paroxysmal and persistent AF; however, this strategy may change during follow-up in both groups. In conclusion, the Euro Heart Survey on atrial fibrillation has provided insight in the characteristics, management and outcome of patients with AF in Europe. As expected, heart failure and AF are frequently associated. Differences in rhythm or rate control strategy among the different AF patients are observed. Furthermore, both pharmacological and electrical cardioversion are widely applied in various forms. Finally, anticoagulant strategy needs more attention, especially in high-risk patients. Further analysis of the data in the Euro Heart Survey on atrial fibrillation may provide additional information on treatment and outcome of patients with AF. -
17
