2010 ESC guidelines on atrial fibrillation followed by seven European countries, PREFER in AF registry shows

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By Angela Gonzalez

Results from the PREFER in AF registry study have shown that seven European countries have adapted to the 2010 European Society of Cardiology (ESC) guidelines on atrial fibrillation (AF). The guideline-recommended use of oral anticoagulation has increased compared to previous registries, as well as the use of antiarrhythmic drugs and catheter ablation procedures.

Preliminary results, reported by Paulus Kirchhof (chair in Cardiovascular Medicine, University of Birmingham Centre for Cardiovascular Sciences and SWBH NHS Trust, Birmingham, UK, and department of Cardiovascular Medicine, University of Munster, Germany) at EHRA Europace (23–26 June, Athens, Greece), were published on 1 October in Europace.

“Clinical guidelines are not always fully implemented into practice, even though most recommendations for the management of AF are based on sound evidence,” said Kirchhof. “Therefore we wanted to conduct a registry to find out to what extent the publication of evidence and the publication of guidelines actually changes behaviour towards treatment of AF patients with focus on prevention of thromboembolic events.”

The researchers conducted PREFER in AF (Prevention of thromboembolic events European registry in atrial fibrillation), a multicentre, prospective, observational registry, in seven European countries (Italy, Germany, France, UK, Spain, Switzerland and Austria). No explicit exclusion criteria were defined to avoid biased selection of patients and achieve a cohort close to real-life.

Data were collected from January 2012 to January 2013. A total of 7,243 consecutive AF patients (mean age 71.5±11 years, 60.1% male) were included (Italy 1,888, Germany 1,580, France 1,532, UK 1,194, Spain 858, Switzerland 127 and Austria 64). Stroke risk was high in the majority of patients. About 30% were cases with paroxysmal AF, 24% with persistent AF and 7.2% with long-standing persistent AF.

“The snapshot of AF management in seven European countries in 2012 suggests that treatment patterns have changed in recent years,” Kirchhof et al wrote. “Overall antithrombotic therapy seen in PREFER in AF suggests much better adherence to evidence and 2010 recommendations than prior reports of similar registries.” The researchers highlighted that in PREFER in AF over 80% of clearly eligible patients received oral anticoagulation therapy (66.3% received a vitamin K antagonist [VKA], 9.9% received a combination of VKA and antiplatelet agents and 6.1% received a new oral anticoagulant) compared to only 70% of eligible patients during 2005–2008. Inappropriate oral anticoagulation therapy in patients without stroke risk factors remains high, according to Kirchhof et al. “Hence, there appears to be a need to better communicate that oral anticoagulation is not indicated in these patients,” they noted.

With regards to the uptake of new oral anticoagulants, the authors considered that this number is “rather low” and limited to the use of dabigatran; however, it should be taken into account that new oral anticoagulants were only beginning to be introduced into the different healthcare systems of the countries captured in the registry, they highlighted.

Amongst other results, Kirchhof et al reported that 78.6% of patients were adequately rate controlled. Rhythm control therapy is more often used, compared to 2004–2006 registries, with almost half of the patients treated with electrical cardioversion (18.1%), pharmacological cardioversion (19.5%), antiarrhythmic drugs (amiodarone 24.1%, flecainide or propafenone 13.5%, sotalol 5.5%, dronedarone 4%) and catheter ablation (5%). Rhythm control therapy was mainly used in symptomatic patients, which is in line with current and prior recommendations, the authors wrote.

“Despite adherence to evidence and guidelines, many patients remain symptomatic, illustrating the need for better strategies to manage AF,” said Kirchhof.

The researchers noted that information on atrial fibrillation from other European countries is expected from the EORP general AF pilot registry of the ESC and other registry initiatives in Europe.

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