Elsevier

American Heart Journal

Volume 153, Issue 6, June 2007, Pages 1006-1012
American Heart Journal

Clinical Investigation
Electrophysiology
Guideline-adherent antithrombotic treatment is associated with improved outcomes compared with undertreatment in high-risk patients with atrial fibrillation. The Euro Heart Survey on Atrial Fibrillation,

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Background

The Euro Heart Survey showed that antithrombotic treatment in patients with atrial fibrillation (AF) was moderately tailored to the 2001 American College of Cardiology, American Heart Association, and European Society of Cardiology (ACC/AHA/ESC) guidelines for the management of AF. What consequences does guideline-deviant antithrombotic treatment have in daily practice?

Methods

In the Euro Heart Survey on AF (2003-2004), an observational study on AF care in European cardiology practices, information was available on baseline stroke risk profile and antithrombotic drug treatment and on cardiovascular events during 1-year follow-up. Antithrombotic guideline adherence is assessed according to the 2001 ACC/AHA/ESC guidelines. Multivariable logistic regression was performed to assess the association of guideline deviance with adverse outcome.

Results

The effect of antithrombotic guideline deviance was analyzed exclusively in 3634 high-risk patients with AF because these composed the majority (89%) and because few cardiovascular events occurred in low-risk patients. Among high-risk patients, antithrombotic treatment was in agreement with the guidelines in 61% of patients, whereas 28% were undertreated and 11% overtreated. Compared to guideline adherence, undertreatment was associated with a higher chance of thromboembolism (odds ratio [OR], 1.97; 95% CI, 1.29-3.01; P = .004) and the combined end point of cardiovascular death, thromboembolism, or major bleeding (OR, 1.54; 95% CI, 1.14-2.10; P = .024). This increased risk was nonsignificant for the end point of stroke alone (OR, 1.42; 95% CI, 0.82-2.46; P = .170). Overtreatment was nonsignificantly associated with a higher risk for major bleeding (OR, 1.52; 95% CI, 0.76-3.02; P = .405).

Conclusions

Antithrombotic undertreatment of high-risk patients with AF was associated with a worse cardiovascular prognosis during 1 year, whereas overtreatment was not associated with a higher chance for major bleeding.

Section snippets

Methods

In the Euro Heart Survey on AF (2003-2004), 5333 ambulant and hospitalized patients with AF were enrolled in cardiology practices. Details of the baseline survey have previously been described.7 Patients were enrolled if they were 18 years or older and if they had an electrocardiogram or Holter recording showing AF during the qualifying admission/consultation or in the preceding 12 months. Patients with only atrial flutter on their electrocardiograms were excluded. Data were collected through

Results

In the initial survey, data on stroke risk profile and antithrombotic drug therapy at discharge were available for 5130 patients who were alive at the end of the baseline visit. Of these patients, survival status at 1-year follow-up was known for 4086 patients (80%). Compared with patients with complete follow-up data, patients for whom no follow-up data were available were enrolled more often at the cardiology ward (65% vs 54%; P < .001) instead of the outpatient clinic (21% vs 37%; P < .001),

Discussion

The Euro Heart Survey on AF is the first observational study to show that antithrombotic undertreatment is associated with worse cardiovascular outcome compared to guideline adherence. Overtreatment was not associated with a significant increase in bleeding risk.

Acknowledgement

Central data collection was done at the European Heart House of the European Society of Cardiology, Sophia Antipolis, France. Data analysis was done at the Department of Cardiology, University Hospital Maastricht, Maastricht, the Netherlands. We thank the Euro Heart Survey team, national coordinators, investigators, and data collection officers for performing the survey.

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Cited by (0)

This study was supported by AstraZeneca (London, United Kingdom), Sanofi-Aventis, and Eucomed (Brussels, Belgium), and by the following institutions: Austrian Heart Foundation (Vienna, Austria), Austrian Society of Cardiology (Vienna, Austria), French Federation of Cardiology (Paris, France), Hellenic Cardiological Society (Athens, Greece), Netherlands Heart Foundation (Hague, The Netherlands), Portuguese Society of Cardiology (Lisbon, Portugal), Spanish Cardiac Society (Madrid, Spain), and the Swedish Heart and Lung Foundation (Stockholm, Sweden).

No other affiliations and no conflict of interest reported.

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