STOCKHOLM – The initial report from the world’s largest atrial fibrillation registry demonstrates that in everyday clinical practice, the arrhythmia is frequently not controlled – and even when it is, most patients remain symptomatic.
Dr. P. Gabriel Steg
The RealiseAF registry data also underscore that real-world patients with atrial fibrillation (AF) have a disturbingly highly cardiovascular event rate, with 29% of the more than 10,000 enrollees having experienced an unplanned hospital admission for a serious cardiovascular event within the past 12 months. The most frequent reasons for admission were acute decompensated heart failure, acute coronary syndromes, stroke, and transient ischemic attack, Dr. P. Gabriel Steg said at the annual congress of the European Society of Cardiology.
The RealiseAF registry provides an unprecedented look at contemporary management of AF in 26 countries. Unlike the highly selected and frequently nonrepresentative patients chosen for clinical trials, the 10,523 enrollees in RealiseAF were consecutive outpatients with all types of AF who were seen in 2010 by cardiologists or primary care physicians at 768 sites, explained Dr. Steg, professor of cardiology at the University of Paris–VII.
One of the registry’s big surprises was how common permanent AF turns out to be in routine clinical practice. Fully 46% of registry participants had permanent AF, a far higher figure than in previous, less comprehensive surveys.
In all, 25% of patients had paroxysmal AF, 22% had persistent AF, and 5% had lone AF. The rest could not be classified because their index AF episode was their first ever.
Among other highlights of RealiseAF were the following findings:
• Control of AF is achieved in just 59% of patients. Only 26.5% of RealiseAF participants were in sinus rhythm, whereas 32.5% achieved rate control (defined as a heart rate of 80 beats per minute or fewer).
• AF control is not synonymous with symptom control. In all, 56% of patients whose AF was controlled experienced at least one symptom – most often dyspnea, palpitations, fatigue, or chest pain – within the past 7 days. Symptoms were even more common in those with uncontrolled AF.
• Rate control is the most popular and least effective AF management strategy. At the end of the office visit on the day of enrollment, rate control was the strategy selected for 56% of patients, whereas rhythm control was chosen for 37%. However, 71% of patients in the rate control group ultimately failed to achieve rate control.
• The AF population is rife with cardiovascular risk factors. Hypertension was present in 72% of RealiseAF participants, and 46% had dyslipidemia; 61% were physically inactive. Furthermore, 77% of AF patients had at least one cardiovascular morbidity: One-third of the population had coronary artery disease, one-quarter had valvular heart disease, and 14% had cerebrovascular disease.
• Adherence to guidelines is far from optimal. Of the 25.6% of RealiseAF patients on amiodarone as first-line antiarrhythmic therapy, one-half did not qualify according to the 2006 joint American College of Cardiology/American Heart Association/European Society of Cardiology AF guidelines. Of the 12% of patients on class Ic antiarrhythmic agents, 20% did not qualify, according to the guidelines.
Moreover, of the more than 6,000 RealiseAF participants who had a CHADS2 score of 2 or more and therefore were supposed to be on warfarin, according to the guidelines, only 53% actually were. At the other end of the risk spectrum, 46% of patients with a CHADS2 score of 0 were on warfarin – contrary to the guidelines – and only 25% were on an antiplatelet drug only, as recommended in the guidelines.
“These results suggest a continuing need for medical education and information,” Dr. Steg noted.
Another key message from the RealiseAF registry is that new antiarrhythmic agents and antithrombotic drugs are sorely needed in order to better manage AF with a view toward improved cardiovascular outcomes, he added.
Disclosures: The registry is sponsored by Sanofi-Aventis. Dr. Steg declared that he serves as a consultant to that pharmaceutical company as well as more than a dozen others.