Assessment of stroke risk in Middle Eastern patients with atrial fibrillation: the Gulf SAFE registry

The Atrial FibriLlatiOn (FLOW-AF) Registry in the Middle East and North Africa: Patient Characteristics, Treatment Patterns and Outcomes

INTRODUCTION

Limited data on atrial fibrillation (AF) are available from the Middle East and North Africa region (MENA). The aim of the FLOW-AF registry was to evaluate the characteristics, treatment patterns, and clinical and economic outcomes of patients with newly diagnosed non-valvular atrial fibrillation (NVAF) in MENA.

METHODS

This multi-center, prospective, observational study (the FLOW-AF registry) enrolled patients newly diagnosed with NVAF across Egypt, Lebanon, Kingdom of Saudi Arabia, and United Arab Emirates. The data collection occurred at enrollment (baseline) and after 6- and 12-months (follow-up). Baseline data included demographics, AF characteristics, medical history, and anti-thrombotic treatment patterns. Clinical events, healthcare resource utilization, and direct costs were collected at follow-up.

RESULTS

The study enrolled a total of 1418 patients (52.7% males and 47.3% females). The mean age of the patients was 64.5 years and 90.6% were white. The mean (standard deviation) CHA2DS2-VASc and HAS-BLED risk scores were 2.7 (1.6) and 1.6 (1.2), respectively. Non-vitamin K antagonist oral anticoagulants, antiplatelet therapy, and vitamin K antagonists were prescribed to 65.8%, 16.4%, and 12.9% patients, respectively. During follow-up, the following rates of clinical outcomes were observed: bleeding events (1.7%), transient ischemic attack (1.7%), all-cause mortality (1.7%), stroke (0.6%), myocardial infarction (0.2%), and systemic embolism (0.08%).

CONCLUSIONS

This MENA patient population was younger and had lower mean baseline CHA2DS2-VASc and HAS-BLED scores. The rates of clinical outcomes over 1-year in this study were low. Longer follow-up is required to comprehensively assess clinical outcomes in this patient population.

Is there a Concordance between CHA2DS2 VASc and HAS-BLED Scores in Middle Eastern Patients with Nonvalvular AF? Analysis of the Jordan Atrial Fibrillation (JoFib) Study

Background:

Nonvalvular Atrial Fibrillation (NVAF) is a common arrhythmia that potentially contributes to stroke and systemic embolization. Anticoagulants may contribute to the risk of bleeding in these patients. Reports of NVAF on Middle Eastern populations are scarce and outdated. This study investigated the concordance between congestive heart failure, hypertension, ≥75 years of age, diabetes mellitus, stroke or transient ischemic attack, vascular disease, 65 to 74 years of age group, sex category (CHA2DS2 VASc), and Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) scores, and the risks of stroke and bleeding in Jordanian NVAF patients.

Methods:

Results were extracted from the Jordan Atrial Fibrillation (JoFib) multicenter registry (NCT03917992). To assess the risk of stroke, a CHA2DS2 VASc score was used. The HAS-BLED score was used to assess the risk of bleeding. Subgroup analysis for males and females was carried out.

Results:

We included 1823 NVAF patients, almost equally distributed among males and females. The overall mean age was 68.2 years. Most patients had a body mass index (BMI) ≥ 25 (71.5%). Almost half of the patients were smokers, 45.5% had diabetes, and 76.3% had hypertension. Paroxysmal AF was the most common subtype (38%), followed by the permanent (28.6%), long-standing (17.3%), and persistent types (16.1%). Females had a significantly higher CHA2DS2 VASc score than males (p=0.012). For the risk of bleeding, 48.9% of patients had a low risk, 31.5% had intermediate risk, and 19.6% had a high risk. A correlation was found between the two scoring systems. Out of the 357 patients who had a high HAS-BLED score, 354 (99.2%) patients also had a high CHA2DS2 VASc score.

Conclusion:

In almost all NVAF patients with a high risk of bleeding (high HAS-BLED score), the use of anticoagulants is highly recommended and strongly indicated according to the CHA2DS2 VASc score stratification. Therefore, strict strategies of well-controlled administration of anticoagulants should always be considered and followed in Middle Eastern patients with NVAF and a high risk of bleeding.

Middle East Treatment Strategies and Clinical Outcomes in Patients with Atrial Fibrillation: One-Year Follow-up Data from Garfield-AF Study

INTRODUCTION

The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) aims to determine real-life treatment patterns and clinical outcomes of patients with newly diagnosed non-valvular atrial fibrillation (AF) and at least one investigator-determined risk factor for stroke. The registry includes a wide array of baseline characteristics and has a particular focus on: (1) bleeding and thromboembolic events; (2) international normalized ratio fluctuations; and (3) therapy compliance and persistence patterns.

METHODS

Evolution in baseline treatment for patients enrolled in sequential cohorts showed an increase in prescribing of novel oral anticoagulants over time. Variability in novel oral anticoagulant prescription is primarily due to differences in availability of treatment and prescribing habits between countries and care settings. The GARFIELD-AF registry also provides insights into clinical management and related outcomes of AF in Middle East populations.

RESULTS

A total of 1660 patients with non-valvular AF (median age 64.0 years, interquartile range 56.0-72.0), mostly diagnosed in cardiology settings from Egypt, the United Arab Emirates and Turkey, were recruited in cohorts 3-5. Data from patient populations in the Middle East related to the rates of stroke/systemic embolism, major bleeding and all-cause mortality 1 year after diagnosis of AF and treatment strategies, based on the stroke and bleeding risk, have been analysed and compared with the rest of the world. The use of antithrombotic treatment in the Middle East was generally higher than the non-Middle East, with increased prescription of antiplatelet therapy (AP) therapy. Appropriate use of Factor Xa inhibitors/direct thrombin inhibitors (DTIs) were 74.4% and Factor Xa/DTI + APs were 70.4% in the overall population, whereas they were 57.1% and 63.6%, respectively, in the Middle East.

CONCLUSION

We have found that rates of stroke and bleeding were lower, although mortality was higher, in the Middle East population. This paper describes the baseline characteristics, patterns of antithrombotic treatment and 1-year outcomes in Middle East AF patients.

TRIAL REGISTRATION

http://www.clinicaltrials.gov . Identifier, NCT01090362.

Adherence to the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline on the Use of Oral Anticoagulant Agents in Middle Eastern Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study

BACKGROUND

There is a scarcity of studies that evaluate adherence to the utilization of guideline-recommended oral anticoagulant agents (OACs) in patients with atrial fibrillation (AF) in the Middle East. The Jordan Atrial Fibrillation (JoFib) Study evaluated baseline clinical profiles and the utilization of OACs, including vitamin K antagonists (VKAs) and direct OACs (DOACs), in patients with valvular AF (VAF) and nonvalvular AF (NVAF) according to the 2019 focused update of the 2014 AHA/ACC/HRS guidelines.

METHODS

Consecutive patients with AF were enrolled in 29 hospitals and outpatient clinics. The use of OACs was evaluated in patients with VAF and NVAF according to the prespecified guideline.

RESULTS

Of 2000 patients, 177 (8.9%) had VAF and 1823 (91.1%) had NVAF. A VKA was prescribed for 88.1% of the VAF group. In the NVAF group, 1468 (80.5%) of patients had a high CHA2DS2-VASc score, i.e., a score of ≥3 in women and ≥2 in men; 202 (11.1%) patients had an intermediate CHA2DS2-VASc score, i.e., a score of 2 in women and 1 in men; and 153 (8.4%) patients had a low CHA2DS2-VASc score, i.e., a score of 1 in women and 0 in men. Of patients with a high CHA2DS2-VASc score, 1204 (82.0%) received OACs, including DOACs for 784 (53.4%) and VKA for 420 (28.6%) patients. Among patients with an intermediate score, OACs were prescribed for 148 (73.3%) patients, including 107 (53.0%) who received DOACs and 41 (20.3%) patients who received VKA. In patients with a low score, OACs were omitted in 94 (61.4%) patients and prescribed for 59 (38.6%) patients. Multivariate analysis showed that age between 50 and 70 years, CHA2DS2-VASc score of ≥2, a diagnosis of stroke or systemic embolization, and nonparoxysmal AF were significantly associated with increased odds of OAC prescription.

CONCLUSIONS

The current status of the utilization of OACs in Middle Eastern AF patients appears to be promising and is consistent with the 2019 focused update of the 2014 AHA/ACC/HRS guideline. This trial is registered with NCT03917992.

Wide Variation in Reported Rates of Stroke Across Cohorts of Patients With Atrial Fibrillation

Background:

Oral anticoagulants decrease ischemic stroke rates in patients with atrial fibrillation (AF) but increase the risk of bleeding. For the average patient with AF, the threshold of annual ischemic stroke rate where the benefit of anticoagulation outweighs the bleeding risk (net clinical benefit) has been shown to be ≈1% to 2%. Guideline recommendations for oral anticoagulants in AF are based on the CHA 2 DS 2 -VASc stroke risk point scores, assuming that those scores translate to fixed stroke rates. However, the relationship between stroke point scores and annual stroke rates may vary substantially across populations. We sought to comprehensively assess the reported rates of stroke in patients with AF and the relationship of stroke rates to stroke risk point scores.

Methods:

A systematic review of cohort studies and randomized controlled trials enrolled patients with nonvalvular AF not treated with oral anticoagulants.

Results:

Of the 3552 studies screened, we identified 34 studies eligible for analysis. Overall stroke rates in cohort studies were highly heterogeneous (Q=5706.54, P <0.001; I 2 = 99.6%) and ranged from 0.45% to 9.28% per year, despite being of similar objective study quality. The mean North American stroke rate was less than one-third that of the mean European stroke rate ( P <0.0001). However, a random effects regression indicated that between-study variability was not significantly accounted for by cohort region, prospective versus retrospective design, calendar year of study, or outcome event cluster. At a CHA 2 DS 2 -VASc score of 1, 76% of cohorts reported ischemic stroke rates <1% per year and only 18% of cohorts reported a stroke rate >2% per year. At a CHA 2 DS 2 -VASc score of 2, 27% of cohorts reported stroke rates below 1% per year, 40% reported stroke rates between 1 and 2% per year, and 33% reported stroke rates >2% per year.

Conclusions:

Substantial variation exists across cohorts in overall stroke rates and rates corresponding to CHA 2 DS 2 -VASc point scores. These variations can affect the point score threshold for recommending oral anticoagulants in AF. The majority of cohorts did not observe stroke rates that would indicate a clear expected net clinical benefit for anticoagulating AF patients with CHA 2 DS 2 -VASc scores of 1 or 2.

Atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, and increases in prevalence with increasing age and the number of cardiovascular comorbidities. AF is characterized by a rapid and irregular heartbeat that can be asymptomatic or lead to symptoms such as palpitations, dyspnoea and dizziness. The condition can also be associated with serious complications, including an increased risk of stroke. Important recent developments in the clinical epidemiology and management of AF have informed our approach to this arrhythmia. This Primer provides a comprehensive overview of AF, including its epidemiology, mechanisms and pathophysiology, diagnosis, screening, prevention and management. Management strategies, including stroke prevention, rate control and rhythm control, are considered. We also address quality of life issues and provide an outlook on future developments and ongoing clinical trials in managing this common arrhythmia.

Epidemiology of classical risk factors in stroke patients in the Middle East

The Middle East (ME) is an ethnically and economically diverse region. A systematic review of all stroke studies conducted in the ME was carried out, with the aim of determining the prevalence of classic vascular risk factors (CRFs) across this region. Additionally, the prevalence of CRFs in the ME was compared to that of a US cohort. Prospective and retrospective ME stroke studies published from 1994 to 2014 were searched for that specifically reported on the prevalence of CRFs. The Z test for proportions was used to determine the significance of differences in CRF rates between the ME and non-ME studies. A total of 21,724 stroke patients from 13 nations in the ME were included. The prevalence rates for CRFs in the ME stroke population were hypertension, 62.1%; diabetes, 33.1%; dyslipidaemia, 36.8%; ischaemic heart disease, 24.6%; smoking, 19.3%; and atrial fibrillation, 13.6%. Compared to the US cohort, ME patients had a lower prevalence of all CRFs except diabetes (P < 0.0001) and smoking (P = 0.05). Compared with stroke patients in the USA, those in the ME have a significantly higher prevalence of diabetes and smoking. Education and lifestyle modification is perhaps the most effective strategy in reducing the risk of stroke in this population.

Global epidemiology of atrial fibrillation

Atrial fibrillation (AF) is a major public health burden worldwide, and its prevalence is set to increase owing to widespread population ageing, especially in rapidly developing countries such as Brazil, China, India, and Indonesia. Despite the availability of epidemiological data on the prevalence of AF in North America and Western Europe, corresponding data are limited in Africa, Asia, and South America. Moreover, other observations suggest that the prevalence of AF might be underestimated-not only in low-income and middle-income countries, but also in their high-income counterparts. Future studies are required to provide precise estimations of the global AF burden, identify important risk factors in various regions worldwide, and take into consideration regional and ethnic variations in AF. Furthermore, in response to the increasing prevalence of AF, additional resources will need to be allocated globally for prevention and treatment of AF and its associated complications. In this Review, we discuss the available data on the global prevalence, risk factors, management, financial costs, and clinical burden of AF, and highlight the current worldwide inadequacy of its treatment.