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Revista argentina de cardiología

versión On-line ISSN 1850-3748

Rev. argent. cardiol. vol.83 no.3 Ciudad Autónoma de Buenos Aires jun. 2015

 

EDITORIAL

Anticoagulation for Atrial Fibrillation in Argentina: Progress and Opportunity

Anticoagulación en la fibrilación auricular en Argentina: progreso y oportunidad

 

M. Cecilia Bahit1, Christopher Granger2

SEE RELATED ARTICLE: Rev Argent Cardiol 2015;83:210-216. http://dx.doi.org/10.7775/rac.v83.i3.5723

1 Chief of Cardiology, INECO Neurociencias Rosario, Argentina
2 Professor of Medicine, Division of Cardiology, Department of Medicine - Duke University Medical Center

 

Atrial fibrillation (AF) is the most common arrhythmia. (1) One out of five strokes is due to atrial fibrillation, and over two thirds of strokes in patients with atrial fibrillation can be prevented with anticoagulation.

AF is also associated with heart failure and increased mortality. (2-5) Several studies suggest a rising prevalence and incidence of AF, in large part due to advancing age, increased comorbidities and cardiovascular risk factors. (6-10) In the United States, it is estimated that the number of adults with AF will increase more than double by the year 2050. (11) Thus, it is important to describe current patterns of practice at a local level in order to implement strategies to improve anticoagulation treatment.

In this issue of the Journal, Roel et al published the results of “Antithrombotic Strategies in Atrial Fibrillation. The XIX CONAREC Registry.” Between September and November 2013, 927 patients with at least one episode of atrial fibrillation in the past 12 months and hospitalized for a cardiovascular cause in centers with cardiology residencies affiliated with the Argentine Council of Residents in Cardiology (CONAREC) were enrolled in the study. Patients had a median age of 73 years and were mostly men, with a median CHADS2 score of 2 and median CHA2DS2- VASc 3. History of diabetes was 17%, hypertension 78.4%, and prior stroke/TIA 12.7%. On admission, patients with AF without contraindications and with CHADS2≥1 (n=253) were treated with oral anticoagulants in 54% of cases (32% VKA, 16% VKA+ASA; 6% NOAC); 19% received no treatment; 23% aspirin alone, and 3% dual antiplatelet therapy. At discharge, there was increase in the use of anticoagulants in this population (39% VKA, 23% VKA+ASA; 8% NOAC).

However, there was still room for improvement because the use of aspirin alone was 14%, dual antiplatelet 4%, and no treatment 11%. The results of the present registry showed some improvement compared to the PENFACRA registry (12) conducted in 2001, where the authors included 840 patients with chronic atrial fibrillation and the rate of use of VKA was 48.5% in patients without contraindications. The findings of the CONAREC XIX Registry during admission were similar to the RENAFA registry (13) conducted in Argentina between 2010 and 2011, where 1052 patients with chronic AF were included. After excluding those patients with contraindications for anticoagulation, the rate of use of VKA was 53.7%. Reasons for not treating with anticoagulation included contraindications, social factors, and patient decision. The common use of aspirin presents an opportunity, since aspirin appears neither effective nor safe, especially for the elderly, for stroke prevention for atrial fibrillation. (14)

The low use of anticoagulants in this study is consistent with similar findings across a number of US and European registries. (15-17) The GARFIELD study, (18) an international, observational registry that included 10,614 patients with AF and at least one risk factor, found that 45.2% of patients were treated with VKA alone, 10.6% both with a VKA and an antiplatelet agent, and 4.5% with a new oral anticoagulant. (17) This manuscript confirms that there is an unmet need for improving the use of oral anticoagulants in patients with atrial fibrillation in Argentina. However, few quality improvement interventions have been evaluated to determine impact on patient care and clinical outcomes for patients with atrial fibrillation to reduce stroke rates. Thus, we designed the IMPACT AF (An International Multicenter clustered randomized controlled trial to imProve treatment with AntiCoagulanTs in patients with atrial fibrillation). (19) IMPACT AF is a prospective cluster-randomized controlled trial to determine whether a comprehensive evaluation and customized multilevel educational interventions will increase the rate of use of oral anticoagulants and persistence of use in patients with atrial fibrillation. The study is currently ongoing in fifty sites in five countries including Argentina (where it is endorsed by the Argentina Society of Cardiolgy), Brazil, Rumania, India and China. If the educational intervention results in an increased rate of use of oral anticoagulation in patients with AF and high risk for stroke, dissemination of such a strategy used in each particular country will be the next step of this project. Further lines of research are needed to close the gap between recommended treatment and current clinical practice.

Conficts of interest

Dr. Granger is consultant for Pfizer, Bayer, Bristol and Boehringer Ingelheim, among other companies.

Dra. Bahit received grants from Bayer, BMS and Boehringer Ingelheim.

(See author´s conflicts of interest forms in the web / Supplementary Material)

REFERENCES

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12. Roel VC, Moukarzel JA, Zaidel EJ, Galli MA, Da Rosa W, Leiva R et al. Antithrombotic Strategies in Atrial Fibrillation. The XIX CONAREC Registry. Rev Argent Cardiol 2015;83:210-216.

13. Labadet C, Liniado G, Ferreirós E P, Molina Viamonte V, Di Toro D, Cragnolino R et al. First National Prospective Multicenter Study of Chronic Atrial Fibrillation in Argentina. Rev Argent Cardiol 2001;69:50-67.

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20. https://clinicaltrials.gov/ct2/show/NCT02082548?term=impact+ af&rank=2

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