Distribution and Risk Profile of Paroxysmal, Persistent, and Permanent Atrial Fibrillation in Routine Clinical Practice Insight From the Real-Life Global Survey Evaluating Patients With Atrial Fibrillation International Registry Chern-En Chiang, MD, PhD; Lisa Naditch-Brûlé, MD; Jan Murin, MD; Marnix Goethals, MD, PhD; Hiroshi Inoue, MD, PhD; James O’Neill, MD; Jose Silva-Cardoso, MD, PhD; Oleg Zharinov, MD, PhD; Habib Gamra, MD; Samir Alam, MD; Piotr Ponikowski, MD, PhD; Thorsten Lewalter, MD; Mårten Rosenqvist, MD, PhD; Philippe Gabriel Steg, MD Background—There is a paucity of international data on the various types of atrial fibrillation (AF) outside the highly selected populations from randomized trials. This study aimed to describe patient characteristics, risk factors, comorbidities, symptoms, management strategy, and control of different types of AF in real-life practice. Methods and Results—Real-life global survey evaluating patients with atrial fibrillation (RealiseAF) was a contemporary, large-scale, cross-sectional international survey of patients with AF who had ≥1 episode in the past 12 months. Investigators were randomly selected to avoid bias. Among 9816 eligible patients from 831 sites in 26 countries, 2606 (26.5%) had paroxysmal, 2341 (23.8%) had persistent, and 4869 (49.6%) had permanent AF. As AF progressed from paroxysmal to persistent and permanent forms, the prevalence of comorbidities, such as heart failure (32.9%, 44.3%, and 55.6%), coronary artery disease (30.0%, 32.9%, and 34.3%), cerebrovascular disease (11.7%, 10.8%, and 17.6%), and valvular disease (16.7%, 21.2%, and 35.8%), increased, and the prevalence of lone AF decreased. Similarly, there was an increase in mean CHADS2 [cardiac failure, hypertension, age, diabetes, stroke (doubled)] score (1.7, 1.8, and 2.2), and more than half of patients (51.0%, 56.7%, and 67.3%) qualified for oral anticoagulants. Almost 90% of patients received ≥1 antiarrhythmic drug, but >60% had European Heart Rhythm Association symptom scores from II to IV. Furthermore, 40.7% of persistent and 49.8% of permanent AF patients were still in AF with a heart rate >80 beats per minute. Conclusions—This survey disclosed high cardiovascular risks and an unmet need in daily practice for patients with any type of AF, especially those with the permanent form.  (Circ Arrhythm Electrophysiol. 2012;5:632-639.) Key Words: antiarrhythmia agents ◼ atrial fibrillation ◼ epidemiology ◼ heart failure ◼ risk factors

A

trial fibrillation (AF) is the most common sustained cardiac arrhythmia and carries an increased risk of stroke, hospitalization, and mortality. The various types of AF (paroxysmal, persistent, or permanent) may differ in terms of clinical characteristics and comorbidities, affecting the management strategy and long-term outcomes.1 It is important to characterize the cardiovascular risk profiles in patients with permanent AF in comparison with patients with paroxysmal or persistent AF.2

Clinical Perspective on p 639 Although information regarding the risk profiles of these various AF subtypes has been reported, most of this information stems from a single country3,4 or from Europe1,5 or North America6 or excludes patients with permanent AF.7 On the other hand, populations enrolled in clinical trials tend to be highly selected and may not reflect patients encountered in routine clinical practice.8 Furthermore, the clinical

Received January 15, 2012; accepted June 19, 2012. From the General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan (C-E.C.); Sanofi, Paris, France (L.N-B.); Department of Internal Medicine and Cardiology, Comenius University, Bratislava, Slovakia (J.M.); Department of Cardiology-Electrophysiology, H.-Hartziekenhuis Roeselare-Menen, Roeselare, Belgium (M.G.); Second Department of Internal Med, University of Toyama, Toyama, Japan (H.I.); Connolly/Mater Hospitals/RCSI, Dublin, Ireland (J.O.); Department of Cardiology, Porto Medical School, Hospital S. João, Porto, Portugal (J.S-C.); National Medical Academy of Postgraduate Education, Kiev, Ukraine (O.Z.); Cardiology A Department, Cardiothrombosis Research Unit, Fattouma Bourguiba University Hospital, Monastir, Tunisia (H.G.); Division of Cardiology, American University of Beirut Medical Centre, Beirut, Lebanon (S.A.); Department of Heart Disease, Medical University, Wroclaw, Poland (P.P.); Academic Hospital, University of Bonn, Bonn, Germany (T.L.); Karolinska Institute, Södersjukhuset, Stockholm, Sweden (M.R.); and INSERM U-698, Paris, France, Université Paris-Diderot, Paris, France, and Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Bichat-Claude Bernard, Paris, France (P.G.S.). Presented, in part, at the Annual Meeting of European Society of Cardiology, Paris, France, August 29, 2011. Correspondence to Chern-En Chiang, MD, PhD, General Clinical Research Center, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Rd, Taipei 112, Taiwan. E-mail [email protected] © 2012 American Heart Association, Inc. Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org

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DOI: 10.1161/CIRCEP.112.970749

Chiang et al   Differences in Risk in the RealiseAF   633 management and epidemiology of AF have been changing rapidly. We need a contemporary, cross-sectional, and international survey of different types of AF to describe their risk profiles and management strategy and to provide further insight of patients with AF in our routine daily practice. The Real-life global survey evaluating patients with atrial fibrillation (RealiseAF) survey was established to describe patient characteristics, cardiovascular risk, types of AF, symptoms, medical history, and management strategies in real-life practice.9

Methods Design As previously published,9 RealiseAF was a cross-sectional observational survey of >10 000 patients with AF seen at >800 sites in 26 countries from October 2009 to May 2010. Participating countries were Algeria, Azerbaijan, Belgium, Bulgaria, Czech Republic, Egypt, Germany, Hungary, India, Ireland, Italy, Lebanon, Lithuania, Mexico, Morocco, Portugal, Russia, Slovakia, Spain, Sweden, Switzerland, Taiwan, Tunisia, Turkey, Ukraine, and Venezuela.

Results RealiseAF included 10 546 patients from 831 sites in 26 countries on 4 continents. Participating physicians were 83.1% cardiologists, 7.8% internists, and 9.1% physicians who defined themselves as both a cardiologist and an internist. Excluding 23 ineligible patients, 675 patients who had a first episode of AF, and 32 patients with missing data on the type of AF, there were 9816 patients eligible for the current analysis, of whom 2606 (26.5%) had paroxysmal, 2341 (23.8%) persistent, and 4869 (49.6%) permanent AF.2 Baseline characteristics are shown in Table 1. Mean age was highest in patients with permanent AF, who also had the longest duration of AF since diagnosis. There were more men than women in all groups (Table 1).

Cardiovascular Risk Factors and Comorbidities

Patients with a history of AF (treated or not, and whatever the rhythm was at the time of inclusion), with at least 1 AF episode documented by standard ECG or by Holter-ECG in the previous 12 months, or documented current AF, who provided written, informed consent, were enrolled. Exclusion criteria were limited to mental disability (such as dementia or significant cognitive disorders), inability to provide written, informed consent, postoperative AF within 3 months of cardiac surgery, and participation in clinical trials investigating AF or antithrombotics during the previous month.

Patients with AF had multiple cardiovascular risk factors, as shown in Table 2. Hypertension was the most common, followed by physical inactivity and dyslipidemia. Approximately a fifth of the patients had diabetes mellitus across the various AF subsets. Although hypertension and dyslipidemia were slightly less frequent in patients with permanent AF than in those with paroxysmal AF, patients with permanent AF had more comorbidities (Table 3). The prevalence of comorbidities, particularly heart failure, coronary artery disease, cerebrovascular disease, valvular heart disease, and chronic pulmonary disease, increased in a stepwise fashion from paroxysmal to persistent to permanent AF. Similarly, the prevalence of lone AF decreased from paroxysmal to persistent and permanent AF.

Selection of Investigators

Distribution of CHADS2 Score

Patients

Participating physicians were randomly selected from a global list of cardiologists and internists (office- and hospital-based) in each country in 2009 to 2010. The ratio of cardiologists to internists was predetermined to reflect the practice in each country so that unbiased recruitment could be achieved. The list and ratio were validated by national coordinators. The maximum duration of enrolment per center was 6 weeks to maximize recruitment of consecutive patients. Each investigator was asked to recruit a minimum of 10 patients and a maximum of 30.

The distribution of CHADS2 scores across the various types of AF is shown in Table 4. The mean CHADS2 score increased, as did the proportion of patients with a CHADS2 score ≥2, as AF progressed from paroxysmal to permanent. Among patients meeting criteria for anticoagulation (CHADS2 ≥2), the percentage of patients actually receiving oral anticoagulant (OAC) was 37.7%, 54.4%, and 59.0% for paroxysmal, persistent, and permanent AF, respectively (P