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European Society of Cardiology

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PREFER in AF shows European clinicians adhere well to AF guidelines

Oral anticoagulation is now used in over 85% of patients with atrial fibrillation (AF) eligible for therapy, according to results from the PREvention oF thromboembolic events – European Registry in Atrial Fibrillation (PREFER in AF) study1 released recently at the Late Breaking Clinical Trials session II at EHRA EUROPACE 2013.

The study, which provides a ‘snapshot’ of clinical practice across five European countries taken in 2012, revealed that novel oral anticoagulants (NOACs) are now used by 6.1% of AF patients, and that use of rhythm control mediations and catheter ablations have also increased.

Between January 2012 and January 2013 the PREFER registry enrolled consecutive patients with AF from 461 centres in France, Germany, Italy, Spain and UK. Altogether 42% of patients were office based, 53% hospital based and 89% were treated by cardiologists. “Since practice patterns can be influenced by the type of physicians, we felt it was important to recruit patients from a number of different settings,” explained presenter Professor Paulus Kirchhof (University of Birmingham, UK).

Professor Paulus Kirchhof (University of Birmingham, UK)

Professor Paulus Kirchhof (University of Birmingham, UK)

Results showed that of the 7,243 evaluable patients enrolled, 30% had paroxysmal AF, 24% persistent AF, 7.2% long standing persistent, and 38.8% had permanent AF.

When medications were examined it was found that 66.3% of patients (4,799) received a vitamin K antagonist (VKA) as monotherapy; 9.9% of patients (720) received VKA and an antiplatelet agents in combination; and 6.1% received NOACs (dabigatran, rivaroxaban or apixaban). Furthermore, antiplatelet agents alone were given to 11.2% of patients (808) and 6.5% of patients (474) received no antithrombotic therapy at all.

Altogether 78.6% of patients were adequately rate controlled, using a mean heart rate of 60 to 100 bpm as the definition.

Rhythm control therapy was given to 66.7 % of patients, with rhythm control consisting of electrical cardioversion in 18.1 % of patients; pharmacological conversion in 19.5%; amiodarone in 24.1%; flecainide in 10.5%; sotalol in 5.5%; dronedarone in 4% and other antiarrhythmic drugs in 3.1% and catheter ablation in 5%. However, over 80% of patients still suffered from AF symptoms despite good rate control.

“PREFER in AF illustrates changes in management of patients with AF since the last ESC guidelines. The registry shows that oral anticoagulant therapy is now much more widely used than in the German Competence Network on Atrial Fibrillation (AFNET) and the Euro Heart Survey registries on AF and suggests that European clinicians are using guidelines well. The rapid uptake of NOACs suggests that these drugs are filling a therapeutic gap,” said Professor Kirchhof.

The investigators believe the study represents the largest European registry on AF to date. The ESC Guidelines for the Management of atrial fibrillation,2 published in 2010, incorporated several ‘evolutionary’ changes in the management of AF including the concept of active AF screening to initiate therapy before complications had occurred and furthermore emphasised that continuous oral anticoagulation was indicated for the majority of AF patients since almost all are at increased risk of stroke.

“We were surprised and puzzled by the high number of patients who suffer from AF despite good rate control,” said Professor Kirchhof. “This indicates that we have more work to do to develop tools to better prevent AF and possibly to better maintain sinus rhythm in the future.” The ongoing EAST (Early treatment of atrial fibrillation for stroke prevention trial) study3 is currently testing whether early use of rhythm control therapy can prevent adverse cardiovascular outcomes in patients with AF compared to usual care.

Speaking to BJC Arrhythmia Watch, Professor Kirchhof said: “We are currently comparing management in different parts of Europe. In the UK, for example, a bit under 4% of patients received one of the NOACs, while e.g. in Spain or Germany, over 11% received these medications, and in Italy, hardly anyone was treated with a NOAC (<1%).”
References

1. Trends in management of patients with atrial fibrillation in 5 European countries. Presented by Professor Paulus Kirchhof.

2. Camm AJ, Kirchhof P, Lip GYH, et al. Guidelines for the management of atrial fibrillation. Euro Heart J 2010;31:2369–429. http://dx.doi.org/10.1093/eurheartj/ehq278

3. www.easttrial.org

Published on: July 30, 2013

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