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Vol. 70. Issue 10.
Pages 883-886 (October 2017)
Scientific letter
DOI: 10.1016/j.rec.2016.11.038
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Differences in the Characteristics and Management of Patients With Atrial Fibrillation Followed-up by Cardiologists and Other Specialists
Diferencias en las características y el tratamiento de los pacientes con fibrilación auricular seguidos por cardiólogos y por otros especialistas
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Lucía Carnero Montoroa, Inmaculada Roldán Rabadánb, Francisco Marín Ortuñoc, Vicente Bertomeu Martínezd, Javier Muñiz Garcíae, Manuel Anguita Sáncheza,
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m.anguita.sanchez@hotmail.com

Corresponding author:
, on behalf of the FANTASIIA study investigators
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
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Tables (2)
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
Table 2. Pharmacological, Antiarrhythmic and Anticoagulant Treatment in the Total Series and Comparison Between Patients Attended by Cardiologists and Noncardiologists
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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 
CHADS2scale  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.

.

References
[1]
J.J. Gómez-Doblas, J. Muñiz, J. Alonso-Martin, en representación de los colaboradores del estudio OFRECE, et al.
Prevalencia de fibrilación auricular en España. Resultados del estudio OFRECE.
Rev Esp Cardiol., 67 (2014), pp. 259-269
[2]
P. Kirchhof, S. Benussi, D. Kotecha, et al.
2016 ESC Guidelines for the management of atrial fibrillation in collaboration with EACTS.
Eur Heart J., 37 (2016), pp. 2893-2962
[3]
M. Anguita, V. Bertomeu, A. Cequier, 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., 68 (2015), pp. 761-768
[4]
V. Barrios, C. Escobar, L. Prieto, et al.
Control de la anticoagulación en pacientes con fibrilación auricular no valvular asistidos en atención primaria en España. Estudio PAULA.
Rev Esp Cardiol., 68 (2015), pp. 769-776
[5]
V. Bertomeu-González, M. Anguita, J. Moreno-Arribas, for the FANTASIIA Study Investigators, et al.
Quality of Anticoagulation With Vitamin K Antagonists.
Clin Cardiol., 38 (2015), pp. 357-364
Copyright © 2016. Sociedad Española de Cardiología
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