Revista Española de Cardiología (English Edition) Revista Española de Cardiología (English Edition)
Rev Esp Cardiol. 2017;70:883-6 - Vol. 70 Num.10 DOI: 10.1016/j.rec.2016.11.038

Differences in the Characteristics and Management of Patients With Atrial Fibrillation Followed-up by Cardiologists and Other Specialists

Lucía Carnero Montoro a, Inmaculada Roldán Rabadán b, Francisco Marín Ortuño c, Vicente Bertomeu Martínez d, Javier Muñiz García e, Manuel Anguita Sánchez a,

a Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
b Servicio de Cardiología, Hospital La Paz, Madrid, Spain
c Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
d Servicio de Cardiología, Hospital Universitario San Juan, San Juan de Alicante, Alicante, Spain
e Instituto de Ciencias de la Salud, Universidad de A Coruña, A Coruña, Spain

Article

To the Editor,

Atrial fibrillation (AF) has a high prevalence, representing 4.4% of the population older than 40 years in Spain.1 The management of this arrhythmia has undergone significant changes, with the emergence of new direct anticoagulants, the development of AF ablation, and new thromboembolic and bleeding risk scales.2 These advances have also made its management more complex. Given its high prevalence, many patients are followed-up in noncardiology settings (internal medicine [IM], primary care [PC]), and there are no data in Spain regarding possible differences in management according to the type of specialist. Over the past year, various registries have been published on nonvalvular AF in Spain, but the majority include patients seen only in cardiology departments3 or PC.4 The FANTASIIA study (Spanish acronym for Atrial fibrillation: Influence of anticoagulation level and type on stroke and bleeding event incidence),5 was designed to include patients attended by both specialties.

The baseline characteristics of the patients monitored by cardiologists and noncardiologists (IM/PC) were analyzed. Between June 2013 and October 2014, 100 investigators (81% cardiologists, 11% PC specialists and 8% IM specialists) enrolled 2178 consecutive patients with nonvalvular AF seen in outpatient consultations throughout Spain. All the investigators worked at centers within the national health care system. The choice of sites and investigators was made in a nonrandomized manner, by invitation of the scientific committee, following the criteria of territorial distribution by autonomous community and hospital level (one third from each level: primary, secondary, and tertiary).

The mean age was 73.8 ± 9.2 years and women accounted for 42.5% of the sample. There were no differences in these variables between the patients attended by IM and PC or between those attended at hospital appointments and those seen in cardiology outpatient consultations. The mean age of the IM/PC patients was 4 years older than that of patients attended by cardiologists (Table 1). There was a slightly higher rate of hypertension and diabetes mellitus among the IM/PC patients. There was a high prevalence of previous heart disease, approximately 48%, which was similar between the 2 groups. There were no differences in bleeding history or in most types of heart disease (including coronary heart disease) (Table 1), with the exception of heart failure, which was more common (32% vs 27%, P = .049) in patients followed-up by IM/PC. AF was more frequently paroxysmal in the patients followed up by cardiology (P < .001) (Table 1). A history of electrical cardioversion and AF ablation, while infrequent in both groups, was more common in the group followed up by cardiologists. There was a high thromboembolic risk, which was greater in the IM/PC patients (mean CHA2DS2-VASc scores of 4.15, vs 3.60; P < .001). Bleeding risk, calculated using the HAS-BLED scale, was moderate and was higher in the IM/PC patients (Table 1).

Table 1. Demographic Characteristics, Cardiovascular Risk Factors, Comorbidities, and Bleeding and Cardiological Histories in the Total Series and Comparison Between Patients Attended by Cardiologists and Noncardiologists

  All Cardiology IM/PC P *
Patients, n 2178 1765 413  
Demographic data
Age, y 73.8 ± 9.2 73.1 ± 9.1 77.1 ± 9.4 < .001
Female 43.85 42.49 49.64 .008
Employment situation: employed 8.72 9.58 5.08 .013
University education 7.85 8.27 6.05 .131
Comorbidity and cardiovascular risk factors
History of hypertension 80.39 79.66 83.54 .074
History of hyperlipidemia 52.30 51.50 55.69 .125
History of diabetes 29.57 28.50 34.14 .024
History of smoking 37.05 37.34 4.60 .676
Current smoker 5.00 5.10 4.60 .432
COPD/OSAS 17.54 17.39 18.16 .712
Renal insufficiency 18.92 18.30 21.55 .129
Dialysis 0.69 0.68 0.73 .918
History of cancer 8.31 8.33 8.23 .949
Peripheral artery disease 6.24 5.84 7.99 .103
History of stroke/TIA 17.13 16.66 19.13 .230
Hemorrhagic stroke 1.01 0.96 1.21 .346
Previous noncerebral embolism 2.07 1.93 2.66 .343
Thyroid dysfunction 11.52 11.84 10.17 .338
Alcohol or drug abuse 3.40 2.95 5.33 .016
Abbreviated Charlson comorbidity index 1.14 ± 0.77 1.11 ± 0.76 1.26 ± 0.78 .031
Bleeding history
Previous major bleeding 3.90 3.80 4.36 .595
Bleeding requiring transfusion 34.12 29.85 50.00 .109
Bleeding requiring surgery 8.24 7.46 11.11 .617
Previous heart disease
Previous heart disease 47.15 47.48 45.76 .529
Heart failure 28.51 27.59 32.45 .049
HF with reduced EF (< 40%) 12.26 12.86 9.69 .044
Previous coronary disease 18.14 18.30 17.43 .681
Coronary stents 9.14 9.58 7.26 .142
Dilated cardiomyopathy 11.29 12.29 7.02 .002
Aortic valve disease 3.08 2.83 4.12 .174
LV hypertrophy due to hypertension 15.66 15.41 16.71 .514
Previous tachycardia 6.34 6.57 5.33 .350
Previous bradycardia 5.37 5.21 6.05 .495
Pacemaker 6.34 5.78 8.72 .027
Resynchroniser 3.31 3.74 1.45 .019
ICD 2.16 2.44 0.97 .045
AF-related history
Type of AF       < .001
Paroxysmal 29.36 30.91 22.76  
Persistent 16.52 16.99 14.53  
Long-term persistent 4.69 4.20 6.78  
Permanent 49.42 47.90 55.93  
Previous electrical cardioversion 17.67 20.06 7.51 < .001
Previous pharmacological cardioversion 22.32 22.95 19.61 .142
Previous AF ablation 4.00 4.60 1.45 .003
Previous atrial closure 0.32 0.34 0.24 .750
CHADS2 scale 2.24 ± 1.24 2.15 ± 1.22 2.46 ± 1.31 < .001
CHA2DS2-VASc scale 3.70 ± 1.52 3.60 ± 1.45 4.15 ± 1.63 < .001
HAS-BLED scale 2.01 ± 1.24 1.91 ± 1.12 2.40 ± 1.53 < .001
Sinus rhythm in baseline ECG 33.63 36.79 20.15 < .001
AF in baseline ECG 60.19 57.63 71.12 < .001

AF, atrial fibrillation; COPD, chronic obstructive pulmonary disease; ECG, electrocardiogram; EF, ejection fraction; HF, heart failure; ICD, implantable cardioverter defibrillator; IM, internal medicine; LV, left ventricle; OSAS, obstructive sleep apnea syndrome; PC, primary care; TIA, transient ischemic attack.
Unless otherwise indicated, values are expressed as percentage or mean ± standard deviation.

* Bilateral.

General cardiovascular drug therapy was similar in both groups, with a slightly higher proportion of diuretics, antiplatelet agents and statins in IM/PC patients (Table 2). Cardiologists used the rhythm control strategy more frequently (43.7% vs 17.3%; P < .001), although the rate control strategy prevailed in both groups (Table 2). A higher proportion of patients followed-up by cardiologists received prophylactic antiarrhythmic drugs (26.9% vs 15.3%, P < .001). All patients received anticoagulants, in line with the study design. In patients receiving vitamin K antagonists, time in therapeutic range calculated using the Rosendaal method was similar, approximately 61% of days (Table 2). The percentage of patients poorly controlled with vitamin K antagonists (time in therapeutic range < 65%) was high, > 50%, but was similar between the 2 groups (53.7% and 52.7%).

Table 2. Pharmacological, Antiarrhythmic and Anticoagulant Treatment in the Total Series and Comparison Between Patients Attended by Cardiologists and Noncardiologists

  All Cardiology IM/PC P *
Patients, n 2178 1765 413  
Control strategy at initial visit
Rhythm 38.70 43.69 17.43 < .001
Rate 61.30 56.31 82.57  
General cardiovascular drugs
Diuretics 57.38 56.09 62.86 .012
Aldosterone antagonists 13.88 13.38 16.02 .164
ACE inhibitors 31.18 30.87 32.52 .513
ARBs 40.13 39.64 42.23 .333
Statins 54.57 53.53 58.98 .046
Antiplatelet agents 10.42 9.23 15.53 < .001
BB 60.29 59.91 61.89 .459
Digoxin 18.04 18.05 17.96 .965
Calcium-channel blockers       .051
No 75.92 76.25 74.51  
Dihydropyridines 13.65 12.98 16.50  
Verapamil 2.40 2.73 0.97  
Diltiazem 8.03 8.03 8.01  
Antiarrhythmic drugs 24.82 26.99 15.53 < .001
Type of antiarrhythmic agent
Flecainide 8.95 9.97 4.61 .124
Propafenone 0.65 0.74 0.24 .324
Amiodarone 12.18 12.70 9.95 .156
Dronedarone 2.58 3.08 0.49 .125
Sotalol 0.46 0.51 0.24 .423
Drug combinations
Inhibitors 13.73 13.78 13.56 .764
BB+digoxin+calcium antagonist 0.28 0.23 0.48 .369
BB+digoxin 10.33 10.37 10.17 .905
BB+calcium antagonist 0.64 0.57 0.97 .357
Digoxin+calcium antagonist 2.48 2.61 1.94 .431
Antiarrhythmics+inhibitors 14.90 15.87 9.69 < .001
Antiarrhythmic+BB 13.09 14.11 8.72 .003
Antiarrhythmic+digoxin 0.37 0.4 0.24 .64
Antiarrhythmic+calcium antagonist 1.24 1.36 0.73 .295
Anticoagulation therapy
VKA 75.51 74.77 78.64 .123
DOAC 24.49 25.23 21.36 .168
Rosendaal TTR (% of days in therapeutic range) 61.2 ± 23.2 61.4 ± 23.2 60.5 ± 22.9 .458
TTR < 65% 52.98 52.79 53.77 .753

ACE inhibitors, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blockers; BB, beta-blockers; DOAC, direct oral anticoagulants; IM, internal medicine; PC, primary care; TTR, time in therapeutic range; VKA, vitamin K antagonists.
Unless otherwise indicated, values are expressed as percentage or mean ± standard deviation.

* Bilateral.

Our study provides data on the differences in characteristics and treatment of patients with nonvalvular AF followed up by cardiologists and noncardiologists in a wide sample of patients in a “real-world” setting. Its main conclusions are as follows: a) in the sample analyzed, some differences were observed between patients attended by cardiologists and by noncardiologists: those seen by IM/PC were older (mean age 4 years older) and had a higher prevalence of comorbidities (especially diabetes mellitus, preserved heart failure, a higher Charlson comorbidity index, and higher CHA2DS2-VASc and HAS-BLED scores); b) there was a high prevalence of structural heart disease (approximately 50%); c) in general, antiarrhythmic treatment was essentially “conservative”, with a clear predominance of rate control over rhythm control strategies; d) rhythm control strategies and their associated procedures were much more widely used in patients followed up by cardiologists, which may be partly related to the age difference and the type of AF; and e) although all the patients had to receive anticoagulation therapy due to the study design, and consequently it is impossible to draw conclusions on differences in the appropriateness of the indications for anticoagulation, the quality of the anticoagulation in patients receiving vitamin K antagonists was poor and was similar between the 2 groups (more than 50% of the patients had a time in therapeutic range < 65%, with these data being similar to those reported by other recent studies in Spain).3, 4 This situation must be improved, regardless of which setting provides treatment and follow-up.

FUNDING

The FANTASIIA registry has an unconditional grant from Pfizer/Bristol-Myers-Squibb.

.

Corresponding author: m.anguita.sanchez@hotmail.com

Bibliography

1. Gómez-Doblas JJ, Muñiz J, Alonso-Martin J, et al, en representación de los colaboradores del estudio OFRECE. Prevalencia de fibrilación auricular en España. Resultados del estudio OFRECE. Rev Esp Cardiol. 2014;67:259-69.
2. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation in collaboration with EACTS. Eur Heart J. 2016;37:2893-962.
3. Anguita M, Bertomeu V, Cequier A, en representación de los investigadores del estudio CALIFA. Calidad de la anticoagulación con antagonistas de la vitamina K en España: prevalencia de mal control y factores asociados. Rev Esp Cardiol. 2015;68:761-8.
4. Barrios V, Escobar C, Prieto L, et al. Control de la anticoagulación en pacientes con fibrilación auricular no valvular asistidos en atención primaria en España. Estudio PAULA. Rev Esp Cardiol. 2015;68:769-76.
5. Bertomeu-González V, Anguita M, Moreno-Arribas J, et al, for the FANTASIIA Study Investigators. Quality of Anticoagulation With Vitamin K Antagonists. Clin Cardiol. 2015;38:357-64.

1885-5857/© 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved

Cookies
x
To improve our services and products, we use cookies (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.
Cookies policy
x
To improve our services and products, we use cookies (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.