Compliance of atrial fibrillation treatment with the ABC pathway in patients with concomitant diabetes mellitus in the Middle East based on the Gulf SAFE registry.

INTRODUCTION: Atrial fibrillation (AF) and diabetes mellitus (DM) constitute a heavy burden on healthcare expenditure due to their negative impact on clinical outcomes in the Middle East. The Atrial fibrillation Better Care (ABC) pathway provides a simple strategy of integrated approach of AF management: A-Avoid stroke; B-Better symptom control; C-Cardiovascular comorbidity risk management. AIMS: Evaluation of the AF treatment compliance to ABC pathway in DM patients in the Middle East. Assessment of the impact of ABC pathway adherence on all-cause mortality and the composite outcome of stroke/systemic embolism, all-cause death and cardiovascular hospitalisations. METHODS: From 2043 patients in the Gulf SAFE registry, 603 patients (mean age 63; 48% male) with DM were included in an analysis of ABC pathway compliance: A-appropriate use of anticoagulation according to CHA2 DS2 -VASc score; B-AF symptoms management according to the European Heart Rhythm Association (EHRA) scale; C-Optimised cardiovascular comorbidities management. RESULTS: 86 (14.3%) patients were treated in compliance with the ABC pathway. During 1-year follow-up, 207 composite outcome events and 87 deaths occurred. Mortality was significantly lower in the ABC group vs non-ABC (5.8% vs 15.9%, P = .0014, respectively). On multivariate analysis, ABC compliance was associated with a lower risk of all-cause death and the composite outcome after 6 months (OR 0.18; 95% CI: 0.42-0.75 and OR 0.54; 95% Cl: 0.30-1.00, respectively) and at 1 year (OR 0.30; 95% Cl: 0.11-0.76 and OR 0.57; 95% Cl: 0.33-0.97, respectively) vs the non-ABC group. CONCLUSIONS: Compliance with the ABC pathway care was independently associated with the reduced risk of all-cause death and the composite outcome in DM patients with AF, highlighting the importance of an integrated approach to AF management.

Practice-derived data on non-vitamin K antagonist oral anticoagulant therapy to complement observations from randomized trials.

Anticoagulation is fundamental in the management of patients with atrial fibrillation (AF). The study aims to provide a comparative review of the major phase III randomized clinical trials (RCTs) and real-world data (RWD) from reliable, high-grade Phase IV studies that assess the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) vs. vitamin K antagonists (VKAs). Observational studies based on nationwide or health insurance database records on the use of NOACs vs. VKAs in patients with AF were included. We performed a comparison of the efficacy and safety characteristics associated with NOACs vs. VKAs in RCTs and RWD. Although RCTs provide strong support for evidence-based practice, RWD may be used to reflect the broader picture of various clinical settings, provide supplementary insight and fulfil knowledge gaps. Both study types confirmed the safety and efficacy of NOACs in preventing stroke and thromboembolism in patients with AF. In comparison to VKAs, NOACs were associated with reduced risk of ischaemic events and lower rates of adverse events such as major bleeding or intracranial haemorrhage. Administration of NOACs might be associated with increased risk of dose-related gastrointestinal bleeding and myocardial ischaemic events, especially in the early treatment period after switching from VKAs. Special care should be taken in challenging clinical situations like severe renal or hepatic impairment when the treatment regimen needs to be considered individually. Randomized clinical trial and RWD studies are complementary and present comparable findings, affirming that NOACs are safe and effective for anticoagulation of patients with AF in daily clinical practice.

Compliance of Atrial Fibrillation Treatment with the Atrial Fibrillation Better Care (ABC) Pathway Improves the Clinical Outcomes in the Middle East Population: A Report from the Gulf Survey of Atrial Fibrillation Events (SAFE) Registry.

Atrial fibrillation (AF) is associated with substantially increased risk of cardiovascular events and overall mortality. The Atrial fibrillation Better Care (A-Avoid stroke, B-Better symptom management, C-Cardiovascular and comorbidity risk management) pathway provides a simple and comprehensive approach for integrated AF therapy. This study's goals were to evaluate the ABC pathway compliance and determine the main gaps in AF management in the Middle East population, and to assess the impact of ABC pathway adherence on the all-cause mortality and composite outcome in AF patients. 2021 patients (mean age 57; 52% male) from the Gulf SAFE registry were studied. We evaluated: A-appropriate implementation of OACs according to CHA2DS2-VASc score; B-symptom control according to European Heart Rhythm Association (EHRA) symptom scale; C-proper cardiovascular comorbidities management. The primary endpoints were the composite cardiovascular outcome (ischemic stroke or systemic embolism, all-cause death and cardiovascular hospitalization) and all-cause mortality. One-hundred and sixty-eight (8.3%) patients were optimally managed according to adherence with the ABC pathway. Over the one-year follow up (FU), there were 578 composite outcome events and 224 deaths. Patients managed with integrated care had significantly lower rates for the composite outcome and mortality comparing to non-ABC group (20.8% vs. 29.3%, p = 0.02 and 7.3% vs. 13.1%, p = 0.033, respectively). On multivariable analysis, ABC compliance was independently associated with reduced risk of composite outcome (HR 0.53; 95% CI 0.36-0.8, p = 0.002) and death (HR 0.46; 95% CI 0.25-0.86, p = 0.015). Integrated ABC pathway adherent care resulted in the reduced composite outcome and all-cause mortality in AF patients from Middle East, highlighting the necessity of promoting comprehensive holistic and integrated care management of AF.

One-year all-cause mortality risk among atrial fibrillation patients in Middle East with and without diabetes: The Gulf SAFE registry.

BACKGROUND: Atrial fibrillation (AF) poses a great risk of mortality, especially when associated with diabetes mellitus (DM). OBJECTIVES: We aimed to investigate the rate and risk factors for mortality among AF patients with and without DM in the population from the Middle East where it has never been investigated before. METHODS: We analyzed the Gulf-SAFE registry, involving patients with nonvalvular AF from the Middle East, for one-year all-cause mortality. The predictive capability of the CHA2DS2-VASc score for death was also investigated. RESULTS: Among a total of 2043 AF patients 606 had DM. Patients with DM were older and had significantly higher prevalence of multiple comorbidities (p < 0.05, respectively). Among patients with DM, age ≥ 75 (relative risk 2.34, 95% confidence interval 1.19-4.61), heart failure (HF) (RR 2.14, 95%CI 1.03-4.43), peripheral vascular disease (PVD) (RR 3.36, 95%CI 1.22-9.30) and chronic kidney disease (CKD) (RR 2.60, 95%CI 1.16-5.81) were independent risk factors for one year all-cause mortality. Patients with DM had significantly higher rates of heart failure and AF-related hospital admissions, all-cause mortality and composite outcome rates, in one year follow up. Among patients with DM, the CHA2DS2-VASc score was predictive of one-year all-cause mortality with c-index of 0.741 (95%CI 0.688-0.794). CONCLUSIONS: AF patients in Middle East with DM have a higher risk for all-cause mortality, HF and AF admission and composite outcome, compared to patients without DM. Multiple risk factors contribute to the higher mortality rate among patients with DM.

Invited review: hypertension and atrial fibrillation: epidemiology, pathophysiology, and implications for management.

Hypertension affects around half of the adult population worldwide, being one of the most common cardiovascular disorders. On a population basis, high blood pressure is considered to be the major independent risk factor for atrial fibrillation (AF). The incidence of both diseases has increased significantly in the recent decades and it is expected to continuously surge in the following years. Due to close relation between the both diseases and their frequent coexistence, hypertension and AF become major health priorities. The multidirectional linking between raised blood pressure and AF is based on complex associations including structural, hemodynamic, neuroendocrine, and autonomic mechanisms. Hypertension provokes excessive fibroblasts proliferation and increased collagen accumulation. It also stimulates cardiomyocytes apoptosis and inflammation, leading to diffused fibrosis and left ventricular hypertrophy development. This is mainly driven by renin-angiotensin-aldosterone system (RAAS) activation, and autonomic dysregulation. Moreover, exposure on long-term stretch due to hypertension causes arterial stiffness with subsequent systolic and diastolic function loss resulting in further heart muscle remodeling. All these pathological changes combined seem influence on myocardial electrical activity, triggering AF development. Given the prevalence and frequent lack of symptoms of both disorders, opportunistic arrhythmia screening in hypertensive patients is needed. In all individuals with established diagnosis of AF, adequate anticoagulation has to be considered for stroke prevention. Blood pressure control is also an essential component of a holistic approach to AF care.

A drug safety evaluation of apixaban for the treatment of atrial fibrillation, acute coronary syndrome, and percutaneous coronary intervention.

Introduction: The non-vitamin K antagonist oral anticoagulants (NOACs) are changing the landscape for stroke prevention in atrial fibrillation (AF) and prevention or treatment of venous thromboembolism (VTE). In patients with AF and concomitant acute coronary syndrome (ACS), the treatment regimen of combined NOACs and P2Y12 inhibitors is gaining popularity.Areas covered: We conducted a review of safety evaluation and effectiveness of apixaban for AF and ACS treatment, both alone and in combination with different antiplatelet treatment regimens. The aim was to provide an overview of apixaban including mechanism of action, indications, adverse events and tolerability.Expert opinion: Apixaban is recommended as a safe, well tolerated and effective oral anticoagulant for reducing the risk of ischemic events among AF patients. It is of value in prevention and treatment of VTE and pulmonary embolism. Comparing to VKA, apixaban was superior in preventing stroke or systemic embolism with lower major bleeding events among AF patients. When combined with dual antiplatelet therapy apixaban may cause dose-related increase in bleeding which reduces the benefit of this treatment regimen among ACS patients but without AF. In those with ACS and concomitant AF, the combination of apixaban with P2Y12 inhibitor appears to be safe and effective.

Should We Judge Stroke Risk by Static or Dynamic Risk Scores? A Focus on the Dynamic Nature of Stroke and Bleeding Risks in Patients With Atrial Fibrillation.

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and a major risk factor for stroke. The number of patients with AF is predicted to increase in the next few decades. AF has also negative impact on quality of life as well as it significantly increases the risk of cardiovascular disease and overall mortality. Because the stroke is a pivotal outcome of AF, its prevention with the use of anticoagulation therapy constitutes an important component of AF management. The decision on oral anticoagulants' prescription should be based on appropriate risk stratification to allow for comprehensive assessment of benefit/hazard ratio of stroke and bleeding along with patients' preference. Several risk scores for stroke and bleeding as well as for stroke and systemic embolism have been developed, mainly in patients on vitamin K antagonists. AF guidelines stress the need for repetitive evaluation of thromboembolic and bleeding risks to tailor optimal AF management. Indeed, risk is not a static "one off" process and it should be adjusted for dynamic nature of risk factors. However, most risk scores are calculated according to baseline characteristics of patients, but the older the patients get, the more comorbidities they acquire, which influences stroke risk significantly. Hence, the default management of every patient with AF should include a regular reassessment of stroke and bleeding risk factors.