The burden of atrial fibrillation in the Netherlands.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained atrial arrhythmia and it is independently associated with an increased morbidity and mortality. As a result of the high prevalence of AF, the economic and clinical impact of the disease is substantial. This study describes the economic and clinical impact of AF in the Netherlands. METHODS: Epidemiological data on AF in the Netherlands were projected on population estimates of the Netherlands in 2009 and combined with data on the cost of AF and its interventions. RESULTS: Overall prevalence of AF in the Netherlands is 5.5% in the population over 55 years, corresponding to about 250,000 AF patients. The prevalence increases with age, and the mean age of AF patients is 69.3 years. Incidence of AF in the Netherlands varies with age, from 1188 new cases in the age group of 55 to 59 up to 7074 new cases in the age group 75 to 79. Total new cases amounts to 45,085 patients per year in the Netherlands. Total costs of AF in the Netherlands are 583 million, of which the majority (70%) were accounted for by hospitalisations and in-hospital procedures. Pharmacotherapeutic management of AF totalled 17 million in the Netherlands in 2009. DISCUSSION: AF is a serious disease with a high clinical and economic burden, especially due to hospitalisations as a result of cardiovascular events. The number of patients with AF in the Netherlands is considerable and will increase with the ageing population in the future.

Statins Do Not Reduce Atrial Fibrillation After Cardiac Valvular Surgery: A Single Centre Observational Study.

INTRODUCTION: Statins may theoretically reduce postoperative atrial fibrillation (AF) in patients after cardiac valvular surgery due to preservation of endothelial function and anti-ischaemic, anti-inflammatory and anti-remodelling effects. METHODS: Two hundred seventy-two patients who underwent cardiac workup and subsequently cardiac valvular surgery without AF and concomitant coronary artery bypass grafting (CABG) at our hospital were selected. Preoperative drug use and postoperative AF were recorded. AF was defined as any episode of AF longer than 10 s. In addition, results from echocardiography and blood samples were retrieved. RESULTS: BASELINE CHARACTERISTICS WERE AS FOLLOWS: mean age was 65 ± 11 years, 142 (52%) patients were male, 189 (70%) had undergone aortic valve surgery and the mean left ventricular ejection fraction was 57 ± 12%. Statins were used by 79 patients (29%). Statin users, more often, had a prior percutaneous coronary intervention (25% vs 9%, p < 0.001) or CABG (24% vs 4%, p < 0.001), diabetes mellitus (22% vs 5%, p < 0.001) and more often used ß-blockers (51% vs 24%, p < 0.001). Patients in the non-statin group more often had surgery on more than one valve (10% vs 3%, p = 0.043) and had a higher cholesterol level (222 ± 48 vs 190 ± 43 mg/dl, p < 0.001). Postoperative AF occurred in 54% (43/79) of the patients with and in 55% (106/193) of the patients without statins (p = 0.941). There was also no difference in the timing of onset of AF or duration of hospital stay. CONCLUSION: In this observational study, statin use was not associated with a reduced incidence of AF in patients after cardiac valvular surgery.

Improving guideline adherence in the treatment of atrial fibrillation by implementing an integrated chronic care program.

Background / Objectives. Atrial fibrillation (AF) is a very frequent and complex disease often associated with other medical conditions. The Euro Heart Survey (EHS) on AF showed that adherence to guidelines may reduce morbidity and mortality in AF patients. Therefore a nurse-driven, guideline-based, ICT-supported integrated chronic care program (ICCP) was developed and implemented in daily practice. The objective of this study is to evaluate the clinical feasibility of the ICCP, with guideline adherence as the endpoint.Methods. 111 ambulant patients referred for treatment of their AF were enrolled in the ICCP. In this group, patients underwent standardised clinical testing and were subsequently managed by a nurse, supported by a dedicated ICT program and supervised by cardiologists. For comparison, we used a recent historical control group of 102 patients who participated in the Maastricht part of the Euro Heart Survey (EHS) on AF. Results. Guideline adherence was excellent within the ICCP and compared favourably with the EHS-AF data concerning both clinical testing (trigger factors recorded in 100 vs. 44%; echocardiogram performed in 99 vs. 88%; thyroid-stimulating hormone level recorded in 96% vs. 63%) as well as treatment (antithrombotic therapy in 90 vs. 78%; rhythm control avoided in completely asymptomatic patients in 100 vs. 54%; class I drugs avoided in patients with structural heart disease in 90 vs. 95%; rhythm control avoided in permanent AF patients in 100 vs. 92%). Conclusion. The high level of guideline adherence suggests that a nurse-driven, guideline-based, ICT-supported ICCP for AF patients is feasible. (Neth Heart J 2010;18:471-7.).

Effect of a simple two-step warfarin dosing algorithm on anticoagulant control as measured by time in therapeutic range: a pilot study.

BACKGROUND: The efficacy and safety of vitamin K antagonists for the prevention of thromboembolism are dependent on the time for which the International Normalized Ratio (INR) is in the therapeutic range. The objective of our study was to determine the effect of introducing a simple two-step dosing algorithm, as compared with dosing by anticoagulation clinic staffs on the basis of their experience, on time in therapeutic range (TTR) of warfarin therapy. METHODS: We compared TTRs of all clinic patients before and after the introduction of a simple two-step dosing algorithm at a single anticoagulation clinic in Canada, between 1 August 2006 and 24 December 2008. TTR was calculated using the linear interpolation method of Rosendaal. RESULTS: We included 873 patients in the 'before' phase and 1088 patients in the 'after' phase. Introduction of the dosing algorithm significantly increased TTR of patients with a therapeutic INR range of 2-3 from 67.2% to 73.2% (P < 0.001), and that of patients with a therapeutic INR range of 2.5-3.5 from 49.8% to 63.8% (P < 0.001). CONCLUSIONS: The introduction of a simple two-step warfarin-dosing algorithm in place of dosing by experienced anticoagulation clinic staff significantly improved mean TTR for patients in a tertiary-care anticoagulation clinic. This inexpensive and widely applicable algorithm has the potential to improve warfarin control.

Atrial tissue Doppler imaging for prediction of new-onset atrial fibrillation.

BACKGROUND: The total atrial conduction time (TACT) is an independent predictor of atrial fibrillation (AF). A new transthoracic echocardiographic tool to determine TACT by tissue Doppler imaging (PA-TDI (the time from the initiation of the P wave on the ECG (lead II) to the A' wave on the lateral left atrial tissue Doppler tracing)) has been developed recently. OBJECTIVE: To test the hypothesis that measurement of PA-TDI enables prediction of new-onset AF. METHODS: 249 Patients without a history of AF were studied. All patients underwent an echocardiogram and the PA-TDI interval was measured. Patient characteristics and rhythm at follow-up were recorded. RESULTS: During a mean (SD) follow-up of 680 (290) days, 15 patients (6%) developed new-onset AF. These patients had a longer PA-TDI interval than patients who remained in sinus rhythm (172 (25) ms vs 150 (20) ms, p = 0.001). Furthermore, the patients developing AF were older, more often had a history of heart failure or chronic obstructive pulmonary disease, more often used alpha blockers, had enlarged left atria and more frequently mitral incompetence on the echocardiogram. After adjusting for potential confounders, Cox regression showed that PA-TDI was independently associated with new-onset AF (OR = 1.375; 95% CI 1.037 to 1.823; p = 0.027). The 2-year incidence of AF was 33% in patients with a PA-TDI interval >190 ms versus 0% in patients with a PA-TDI interval <130 ms (p = 0.002). CONCLUSIONS: A prolonged PA-TDI interval may predict the development of new-onset AF. This measure may be used to identify patients at risk in future strategies to prevent the development or complications of AF.

Antithrombotic drug prescription in atrial fibrillation and its rationale among general practitioners, internists and cardiologists in The Netherlands--The EXAMINE-AF study. A questionnaire survey.

The objective of the EXAMINE-AF study was to record and compare antithrombotic treatment in patients with atrial fibrillation (AF) in daily clinical practice of general practitioners, internists and cardiologists in the Netherlands. Eighty-six general practitioners, 93 internists and 99 cardiologists responded to postal questionnaires and enrolled 1596 patients: 365, 351 and 880 respectively. A cardiologist was indicated to be the main treating physician for AF in 82% of all patients; current antithrombotic treatment was initiated in 80% by a cardiologist. Of all patients, 84% were at high risk for stroke and therefore were eligible for oral anticoagulation treatment, but only 64% actually received this. Cardiologists instituted appropriate antithrombotic treatment best, compared with general practitioners and internists (70% vs. 58% and 55%; p < 0.001). Positive predictive factors for oral anticoagulation prescription were previous stroke/transient ischaemic attack (OR, 2.31; 95% CI, 1.33-4.02) and heart failure (OR, 1.72; 95% CI, 1.23-2.42). Contraindications for oral anticoagulation (OR, 0.46; 95% CI, 0.32-0.68), treatment by a general practitioner (OR, 0.29; 95% CI, 0.20-0.42) or internist (OR, 0.24; 95% CI, 0.15-0.39) were important factors for withholding treatment. Antithrombotic treatment in AF patients is well instituted in primary and secondary care in the Netherlands. Cardiologists play a key role in the diagnosis and management of the majority of AF patients, even in those regularly attending other physicians. Factors for oral anticoagulation prescription are heart failure, physician specialty and contraindications. Availability of guidelines seems instrumental for application of appropriate antithrombotic treatment.

Which factors are associated with the application of reperfusion therapy in ST-elevation acute coronary syndromes?. Lessons from the Euro Heart Survey on Acute Coronary Syndromes I.

BACKGROUND/AIMS: A large proportion of patients with a ST-elevation acute coronary syndrome do not receive reperfusion therapy. In order to contribute to a better understanding of the clinical decision making process, we analyzed which factors are associated with the application of reperfusion therapy. METHODS: From the Euro Heart Survey of Acute Coronary Syndromes I, 4,260 patients with ST-elevation acute coronary syndrome were selected for the current analysis, of which 1,539 (36%) patients received fibrinolysis and 904 (21%) primary percutaneous coronary intervention (PCI). The analysis contained 32 variables on demographics, medical history, admission parameters and reperfusion therapy. RESULTS: A short pre-hospital delay, arrival in a hospital with PCI facilities, severe ST-elevation, and participation in a clinical trial were the strongest predictors for receiving reperfusion therapy. Primary PCI was more likely to be performed than fibrinolysis in patients with a long pre-hospital delay, arriving in a hospital with PCI facilities, not participating in a clinical trial, and with at least one previous PCI. CONCLUSION: Hospital facilities and culture, pre-hospital delay and infarction size play a major role in management decisions regarding reperfusion therapy in ST-elevation acute coronary syndrome. This analysis indicates which factors require special attention when implementing and reviewing the reperfusion guidelines.

[Treatment of patients with acute coronary syndromes in the Netherlands in 2000-2001; a comparison with other European countries and with the guidelines]. / Behandeling van patiënten met acute coronaire syndromen in Nederland in 2000/'01; een vergelijking met andere Europese landen en met de richtlijnen.

OBJECTIVE: To determine whether the guidelines for the management of acute coronary syndrome (ACS) are being applied in daily clinical practice, and in what ways the management differs between the Netherlands and other member countries of the European Society of Cardiology (ESC). DESIGN: Prospective, observational study. METHOD: Patients with a confirmed diagnosis of ACS who were enrolled in 6 Dutch hospitals and in 97 hospitals in 24 other ESC member countries in the period from 4 September 2000 to 15 May 2001 were included. Data were collected on the acute treatment and secondary prevention in patients with ST-elevation and on the pharmacotherapy, risk stratification and secondary prevention in patients without ST-elevation. The findings were compared with the recommendations and guidelines of the ESC. RESULTS: A total of 223 patients with ST-elevation and 198 patients without ST-elevation were enrolled in the Netherlands, plus 4208 and 5169 patients, respectively, in the other European countries. The median age was 64-67 years and the percentage of males was 64-73. Of the patients with ST-elevation who arrived in the hospital within 12 hours after the onset of symptoms, 35% received neither thrombolysis nor primary percutaneus coronary intervention. In both the Netherlands and the rest of Europe, half of the ST-elevation patients received thrombolysis later than 40 minutes and primary percutaneous coronary intervention later than 90 minutes after arrival in the hospital. Risk stratification using troponin measurements was applied more often in the Netherlands. Of the high-risk patients without ST-elevation, over 50% in both the Netherlands and the rest of Europe underwent coronary angiography. Almost 70% and 80% of low-risk, non-ST-elevation patients underwent an exercise tolerance test or coronary angiography. In the Netherlands, clopidogrel, glycoprotein IIb/IIIa antagonists and statins were prescribed more often and ACE inhibitors less often. CONCLUSION: Guidelines for the management of ACS were followed to a moderate extent in both the Netherlands and the rest of Europe. The management differed in a number of ways between the Netherlands and the other countries.

Continuously improving the practice of cardiology.

Guidelines for the management of patients with cardiovascular disease are designed to assist cardiologists and other physicians in their practice. Surveys are conducted to assess whether guidelines are followed in practice. The results of surveys on acute coronary syndromes, coronary revascularisation, secondary prevention, valvular heart disease and heart failure are presented. Comparing surveys conducted between 1995 and 2002, a gradual improvement in use of secondary preventive therapy is observed. Nevertheless, important deviations from established guidelines are noted, with a significant variation among different hospitals in the Netherlands and in other European countries. Measures for further improvement of clinical practice include more rapid treatment of patients with evolving myocardial infarction, more frequent use of clopidogrel and glycoprotein IIb/IIIa receptor blockers in patients with acute coronary syndromes, more frequent use of ß-blockers in patients with heart failure and more intense measures to encourage patients to stop smoking. Targets for the proportion of patients who might receive specific therapies are presented.