What have we learned from the EORP AF registries?
ARRHYTHMIAS UPDATE 2018Thessaloniki, Greece23-24 March 2018
Tatjana S. Potpara, MD, PhD, FESC
Assist. Professor in Cardiology, School of Medicine, Belgrade University
Head of Dept. for arrhythmia intensive care, Cardiology Clinic, CCS
President of the Serbian AF Association (SAFA)
EHRA Scientific Document Committee member
EORP-AF III Registry Chairperson
SAFASerbian AF Association
www.serbianaf.com
https://www.escardio.org/Research/Registries-&-surveys
Collecting data on cardiovascular disease in Europe
• 2000 – Euro Heart Survey programme• 2009 – EORP
EORP-AF Pilot1
2012-2014EORP-AF Long Term2
2013-2018EORP-AF III3
2018
The EORP (EuroObservational Research Program) Registries On Atrial Fibrillation
AF General Registries
AF Ablation Registries
EORP-AF Ablation Pilot4
2012-2014EORP-AF Ablation Long Term5
2013-2018
1Lip GYH, et al. Europace 2014;16:308–319; 2Boriani G, et al. Europace 2017;DOI:10.1093/europace/eux301; 3https://www.escardio.org/Research/Registries-&-surveys/Observational-registry-programme/atrial-fibrillation-3-registry; 4Arbelo E, et al. Europace 2012;14:1094–1103: 5Arbelo E, et al. Eur Heart J 2017; 38:1303–1316.
9 ESC countries:West: Belgium, Denmark, Netherlands, and Norway; East: Poland and Romania; South: Greece, Italy, Portugal.
EORP-AF General Pilot1
EORP-AF General Long-Term2
27 European countries:Northern Europe: Denmark, Estonia, Latvia, Norway, UK; Western Europe: Belgium, France, Germany, Netherlands, Switzerland;Eastern Europe: Bulgaria, Czech Republic, Georgia, Kazakhstan, Kyrgyzstan, Poland, Romania, Russia; Southern Europe: Albania, FYR Macedonia, Italy, Malta, Montenegro, Portugal, Serbia, Spain, Turkey.
1Lip GYH, et al. Europace 2014;16:308–319; 2Boriani G, et al. Europace 2017;DOI:10.1093/europace/eux301.
The EORP-AF General Registries participation
South: Greece, Italy, Spain; East: Czech Republic, Poland; West/North: Belgium, Denmark, France, Germany, the Netherlands.
EORP-AF Ablation Pilot1: 10 ESC countries
EORP-AF Ablation Long-Term2: 27 ESC countries
1Arbelo E, et al. Europace2012;14:1094–1103: 2Arbelo E, et al. EurHeart J 2017; 38:1303–1316.
PATIENT CHARACTERISTICS AF GeneralPilot
AF GeneralLong-Term
AF AblationPilot
AF AblationLong Term
N of patients 3119 11,096 1391 3593
Mean age, years 68.8 69.0 60.0 59.0
Female sex 40.4% 40.7% 27.9% 31.9%
Comorbidity
Hypertension 70.9% 62.1% 50.0% 54.6%
CAD 36.4% 29.3% 3.6% 18.9%
Congestive HF 47.5% 39.5% 2.6% 22.2%
Diabetes mellitus 20.6% 23.0% 8.3% 9.7%
Prior stroke 6.4% 6.2% 6.8% NR
Prior TE event 13.1% 11.6% 1.9% 6.4%
Chronic kidney disease 13.2% 12.5% 1.8% NR
Patient characteristics and comorbidity in the EORP-AF Registries1-4
1Lip GYH, et al. Europace 2014;16:308–319; 2Boriani G, et al. Europace 2017;DOI:10.1093/europace/eux301; 3Arbelo E, et al. Europace 2012;14:1094–1103: 4Arbelo E, et al. Eur Heart J 2017; 38:1303–1316.
Regional differences in patient characteristics and comorbidity in the EORP-AF General Pilot Registry
Whole cohort,
N=902
WEST (Belgium, Denmark,
Netherlands, Norway), N=125
EAST(Poland, Romania),
N=462
SOUTH(Greece, Italy, Portugal), N=315
P
Age (mean±SD) 71.2±11.3 70.2±12.2 69.1±10.7 74.5±11.0 <0.0001
Female sex 41.0% 36.8% 44.2%38.1% 38.1% 0.1414
AF type
First detected 36.5% 30.5% 32.7% 44.2% <0.0001
Persistent 12.5% 9.3% 12.5% 13.8%
Long-standing persist. 2.4% 2.5% 4.0% 0.0%
Permanent 29.5% 17.0% 32.0% 30.8%
ANTIARRHYTHMIC DRUG (AAD) USE
AF GeneralPilot
AF GeneralLong-Term
N of patients 3119 11,096
Any AAD 36.0% 27.8%
Amiodarone 21.5% 17.9%
Dronedarone 0.3% 0.3%
Propafenone 5.3% 3.6%
Flecainide 5.0% 3.3%
Sotalol 4.4% 2.7%
30.30%
26.50%
21.20%
4.80% 17.20%First-detected
Paroxysmal
Persistent
Long-term persistent
Permanent
EORP-AF General Pilot Registry1
15.60%
25.70%
19.10%
4.30%
33.50%
1.70%
First-detected
Paroxysmal
Persistent
Long-term persistent
Permanent
Unknown
EORP-AF General Long-Term Registry2
AF clinical type and the rates of AADs use in the EORP-AF General Registries
1Lip GYH, et al. Europace 2014;16:308–319; 2Boriani G, et al. Europace 2017;DOI:10.1093/europace/eux301.
Stroke and bleeding risks in the EORP-AF Registries
EORP-AF RegistryCHA2DS2-VASc
meanCHA2DS2-VASc
medianHAS-BLED
mean
General Pilot1 3.24±1.80 3.0 (2.0-4.0) 1.37±1.06
General Long-Term2 3.14±1.77 3.0 (2.0-4.0) 2.84±1.70
Ablation Pilot3 1.70±1.40 NR NR
Ablation Long-Term4 0: 23.2%1: 29.9%≥2: 46.9%
NR 0-2: 98.8%≥3: 1.2%
1Lip GYH, et al. Europace 2014;16:308–319; 2Boriani G, et al. Europace 2017;DOI:10.1093/europace/eux301; 3Arbelo E, et al. Europace 2012;14:1094–1103: 4Arbelo E, et al. Eur Heart J 2017; 38:1303–1316.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Anyantithrombotic
VKA NOACs Dabigatran Rivaroxaban Apixaban ASA Clopidogrel No therapy
General Pilot General Long-Term
The use of antithrombotic therapies in the EORP-AF General Registries1,2
1Lip GYH, et al. Europace 2014;16:308–319; 2Boriani G, et al. Europace 2017;DOI:10.1093/europace/eux301.
2012 2016
Proportion of NOACs use within the overall use of OAC before the enrollment visit/hospitalization (light blue) and after the enrolling visit/at discharge (dark blue).
The Patterns of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) Use in Patients with Atrial Fibrillation in Seven Balkan Countries: a Report from the BALKAN-AF Survey
Potpara TS, Trendafilova E, Dan GA, Goda A, Kusljugic Z, Manola S, Music Lj, Gjini V, Pojskic B, Popescu MI, Georgesku C, Dimitrova E, Kamenova E, Ekmeciu U, Mrsic D, Nenezic A, Brusich S, Milanov S, Zeljkovic I, Lip GYH,
on behalf the BALKAN-AF InvestigatorsAdv Ther (2017) 34:2043–2057
1Lip GYH, et al. Europace 2014;16:308–319; 2Boriani G, et al. Europace 2017;DOI:10.1093/europace/eux301.
Overall OAC use: 79.9% Overall OAC use: 84.9%
OR 95%CI P
Female sex 1.18 1.02-1.37 0.0245
VHD 0.66 0.56-0.77 <0.001
CHF 0.63 0.55-0.73 <0.001
CAD 0.18 0.15-0.21 <0.001
PAD 0.55 0.44-0.69 <0.001
DM 0.75 0.63-0.89 0.0012
AF Type* 0.85 0.73-0.99 0.0474
Factors associated with OAC prescription (OAC alone – VKA or NOAC)
Factors associated with NOAC prescription
OR 95%CI P
VHD 0.58 0.45-0.76 <0.0001
Previous stroke/TIA 1.54 1.06-2.25 0.0235
CHF 0.64 0.49-0.84 0.0010
CAD 0.49 0.35-0.66 <0.0001
PAD 0.49 0.28-0.85 0.0092
Heart rhythm strategy* 1.51 1.08-2.11 0.0153
*Reference: First detected AF
*Reference: Rhythm control only
OR 95%CI P
Age (ref <65Y) 1.59 1.30-1.93 <0.0001
Female sex 0.70 0.58-0.85 0.0002
VHD 1.96 1.60-2.41 <0.0001
Prior stroke/TIA 0.58 0.38-0.89 0.0159
CHF 2.34 1.94-2.82 <0.0001
HTN 1.81 1.45-2.25 <0.0001
CAD 8.55 6.88-10.62 <0.0001
PAD 2.51 1.95-3.21 <0.0001
DM 0.85 0.70-1.04 <0.0001
Heart rhythm strategy* 0.58 0.43-0.79 0.0004
*Reference: Rhythm control only
Factors associated with the prescription of OAC in combination with APLT
Factors associated with the prescription of APLT alone
OR 95%CI P
Female sex 1.24 1.01-1.53 0.0428
Prior stroke/TIA 0.58 0.38-0.89 0.0123
CAD 1.71 1.36-2.14 <0.0001
DM 0.75 0.57-0.99 0.0426
AF type* 1.48 1.19-1.84 0.0004
*Reference: First detected AF
Antithrombotic drug prescription at inclusion and discharge when pharmacologic cardioversion (A), electrical cardioversion (B) or AF ablation (C) was performed or planned at discharge
Whole cohort
N=902
WEST (Belgium, Denmark,
Netherlands, Norway), N=125
EAST(Poland,
Romania),
N=462
SOUTH(Greece, Italy, Portugal), N=315
P
CHA2DS2-VASc score
0 2.1% 6.4% 2.0% 0.6% <0.0001
1 5.8% 12.8% 5.0% 4.1%
≥2 92.1% 80.8% 93.0% 95.3%
HAS-BLED score
0-2 79.9% 95.2% 82.0% 70.8% <0.0001
≥3 20.1% 4.8% 18.0% 29.2%
Regional differences in presentation and treatment of patients with AF in Europe: a report from the EORP-AF Pilot General Registry Lip GYH, Laroche C, Boriani G, Dan GA, Santini M, Kalarus Z, RasmussenLH,Oliveira MM, Mairesse G, Crijns HJGM,Simantirakis E, Atar D, Maggioni AP, Tavazzi L.
Europace 2015;17:194–206.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
Prior TE Prior TIA Prior stroke CHF HTN CAD PAD DM Prior bleed Malignancy CKD
Overall WEST EAST SOUTH
P=NS
P=0.0005 P=NS
P<0.0001P<0.0001
P=NS
P<0.0001P=NS
P<0.0001
P<0.0001
P=NS
Regional differences in presentation and treatment of patients with AF in Europe: a report from the EORP-AF Pilot General Registry Lip GYH, Laroche C, Boriani G, Dan GA, Santini M, Kalarus Z, RasmussenLH,Oliveira MM, Mairesse G, Crijns HJGM,Simantirakis E, Atar D, Maggioni AP, Tavazzi L.
Europace 2015;17:194–206.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
OAC alone APLT alone OAC+APLT None/Unknown Other
Overall WEST EAST SOUTH
Regional differences in presentation and treatment of patients with AF in Europe: a report from the EORP-AF Pilot General Registry Lip GYH, Laroche C, Boriani G, Dan GA, Santini M, Kalarus Z, RasmussenLH,Oliveira MM, Mairesse G, Crijns HJGM,Simantirakis E, Atar D, Maggioni AP, Tavazzi L.
Europace 2015;17:194–206.
Age* Female sex VHD Prior stroke /
TIA
CHF HTN CAD PAD DM AF type# Heart rhythm
strategy§
Any OAC
WEST 1.250.91-1.72
1.04 0.75-1.45
0.810.58-1.13
1.070.62-1.84
0.750.51-1.11
1.421.04-1.95
0.200.14-0.30
0.580.25-1.33
0.980.64-1.52
0.750.52-1.08
0.800.55-1.17
EAST 0.710.57-0.89
1.331.07-1.65
0.700.55-0.90
1.410.95-2.11
0.700.55-0.90
0.980.76-1.27
0.230.18-0.30
0.470.32-0.67
0.840.65-1.08
1.100.87-1.40
1.711.16-2.53
SOUTH 1.080.82-1.41
1.321.03-1.70
0.790.60-1.04
1.190.80-1.79
0.880.68-1.14
1.07081-1.41
0.130.10-0.18
0.750.53-1.05
0.660.49-0.90
0.760.59-0.98
0.820.57-1.18
NOAC
WEST 1.100.73-1.66
1.170.77-1.76
1.130.75-2.60
1.401.75-2.60
0.850.51-1.42
1.230.82-1.85
0.610.36-1.06
1.310.44-3.95
1.120.65-1.92
1.591.03-2.47
0.740.44-1.25
EAST 0.980.64-1.49
1.110.74-1.68
0.660.43-1.03
2.121.17-3.82
0.720.47-1.11
1.260.75-2.12
0.500.31-0.82
0.590.27-1.31
0.970.60-1.58
1.751.15-2.66
2.071.17-3.67
SOUTH 0.350.20-0.62
0.950.53-1.71
0.290.15-0.53
1.160.48-2.78
0.570.28-1.14
0.640.35-1.16
0.330.13-0.85
0.350.11-1.13
0.530.22-1.27
0.510.26-1.01
2.341.19-4.61
*Reference: ≤65y; #Reference: First detected; §Reference: Others.
Regional differences in presentation and treatment of patients with AF in Europe: a report from the EORP-AF Pilot General Registry
Lip GYH, Laroche C, Boriani G, Dan GA, Santini M, Kalarus Z, RasmussenLH,Oliveira MM, Mairesse G, Crijns HJGM,Simantirakis E, Atar D, Maggioni AP, Tavazzi L.
Europace 2015;17:194–206.
Regional differences in presentation and treatment of patients with AF in Europe: a report from the EORP-AF Pilot General Registry
Lip GYH, Laroche C, Boriani G, Dan GA, Santini M, Kalarus Z, RasmussenLH,Oliveira MM, Mairesse G, Crijns HJGM,Simantirakis E, Atar D, Maggioni AP, Tavazzi L.
Europace 2015;17:194–206.
Age* Female sex VHD Prior stroke / TIA
CHF HTN CAD PAD DM AF type# Heart rhythm
strategy§
APLT
WEST 0.580.33-1.02
1.190.66-2.14
1.350.72-2.54
0.590.18-1.93
1.100.53-2.29
0.460.26-0.82
2.811.45-5.41
0.550.07-4.17
0.730.30-1.75
1.040.53-2.03
1.520.80-2.89
EAST 1.831.31-2.54
1.240.91-1.68
0.830.60-1.17
0.670.36-1.25
0.960.69-1.33
0.930.65-1.32
1.731.25-2.41
0.660.38-1.14
0.700.48-1.02
1.721.26-2.35
1.290.79-2.10
SOUTH 0.630.44-0.91
1.110.78-1.57
0.820.57-1.20
0.480.24-0.98
0.300.19-0.47
1.030.70-1.53
1.110.76-1.64
0.980.61-1.59
0.700.44-1.11
1.201.03-2.61
1.641.03-2.61
OAC+ASA
WEST 1.941.19-3.16
0.880.55-1.41
1.410.91-2.19
1.180.58-2.38
1.540.94-2.52
1.991.24-3.19
6.403.97-10.3
4.611.93-11.0
1.510.87-2.61
0.910.54-1.55
1.160.69-1.95
EAST 1.331.02-1.73
0.690.54-0.90
2.051.49-2.81
0.990.63-1.57
1.881.39-2.54
1.451.06-1.99
5.153.80-6.97
2.491.74-3.56
1.601.21-2.13
0.740.55-0.98
0.450.30-0.77
SOUTH 2.551.65-3.93
0.480.33-0.69
1.741.19-2.53
1.601.00-2.57
2.581.85-3.59
1.731.15-2.60
19.812.8-30.6
2.161.46-3.20
2.081.44-2.99
0.950.68-1.34
0.560.31-1.00
*Reference: ≤65y; #Reference: First detected; §Reference: Rhythm control only.
69.2%
80.0%
66.6% 69.2%
54.4%
70.2%74.3%
US NCDRPINNACLE
EORP-Pilot CAPR (China) Brasil PINNACLE FUSHIMI (Japan) KICS (Japan) BALKAN-AF
J Am Heart Assoc. 2016;5:e004037
PROGNOSIS AND TREATMENT OF AF PATIENTS BY EUROPEAN CARDIOLOGISTS: 1-year follow-up of the EORP-AF Pilot Registry
Lip GYH, Laroche C, Ioacim M, Rasmussen LH, Vitali-Serdoz L, Petrescu L, Darabantiu D, Crijns HJGM, Kirchhof P, Vardas P, Tavazzi L, Maggioni AP, Boriani G.
Eur Heart J 2014; 35:336—3376.
All-cause mortality: 5.7% (177/3119)
PROGNOSIS AND TREATMENT OF AF PATIENTS BY EUROPEAN CARDIOLOGISTS: 1-year follow-up of the EORP-AF Pilot Registry
Lip GYH, Laroche C, Ioacim M, Rasmussen LH, Vitali-Serdoz L, Petrescu L, Darabantiu D, Crijns HJGM, Kirchhof P, Vardas P, Tavazzi L, Maggioni AP, Boriani G.
Eur Heart J 2014; 35:336—3376.
Stroke/TIA/peripheral embolism and/or mortality
PROGNOSIS AND TREATMENT OF AF PATIENTS BY EUROPEAN CARDIOLOGISTS: 1-year follow-up of the EORP-AF Pilot Registry
Lip GYH, Laroche C, Ioacim M, Rasmussen LH, Vitali-Serdoz L, Petrescu L, Darabantiu D, Crijns HJGM, Kirchhof P, Vardas P, Tavazzi L, Maggioni AP, Boriani G.
Eur Heart J 2014; 35:336—3376.
• 5 fatal strokes• 15 non-fatal strokes
PROGNOSIS AND TREATMENT OF AF PATIENTS BY EUROPEAN CARDIOLOGISTS: 1-year follow-up of the EORP-AF Pilot Registry
Lip GYH, Laroche C, Ioacim M, Rasmussen LH, Vitali-Serdoz L, Petrescu L, Darabantiu D, Crijns HJGM, Kirchhof P, Vardas P, Tavazzi L, Maggioni AP, Boriani G.
Eur Heart J 2014; 35:336—3376.
Contemporary stroke prevention strategies in 11 096 European patients with AF: a report from the EORP-AF Long-Term General Registry
Boriani G, Proietti M, Laroche C, Fauchier L, Marin F, Nabauer M, Potpara T, Dan GA, Kalarus Z, Diemberger I, Tavazzi L, Maggioni AP, Lip GYH.
Europace 2017; doi:10.1093/europace/eux301
OR 95%CI P
Age 1.02 1.01-1.02 <0.0001
HTN 1.36 1.17-1.58 <0.0001
MI 0.75 0.61-0.91 0.0046
Lone AF 0.32 0.26-0.40 <0.0001
Prior stroke 1.63 1.19-2.24 0.0024
Prior bleed 0.42 0.33-0.54 <0.0001
CKD 0.78 0.64-0.95 0.0152
Malignancy 0.72 0.57-0.91 0.0063
OR 95%CI P
Pharmacological CV 0.81 0.69-0.96 0.0126
ECV 1.82 1.46-2.26 <0.0001
AF Catheter ablation 1.64 1.14-2.26 0.0075
First-detected AF Ref Ref Ref
Parox AF 0.92 0.76-1.11 0.389
Persist AF 2.21 1.75-2.79 <0.0001
LS Pers AF 2.60 1.72-3.94 <0.0001
Permanent AF 2.21 1.80-2.73 <0.0001
Multivariable predictors of anticoagulant therapy
Contemporary stroke prevention strategies in 11 096 European patients with AF: a report from the EORP-AF Long-Term General Registry
Boriani G, Proietti M, Laroche C, Fauchier L, Marin F, Nabauer M, Potpara T, Dan GA, Kalarus Z, Diemberger I, Tavazzi L, Maggioni AP, Lip GYH.
Europace 2017; doi:10.1093/europace/eux301
Region OR 95%CI P
Eastern Europe (reference)
Southern Europe 1.44 1.21-1.72 <0.0001
Northern Europe 1.69 1.33-2.14 <0.0001
Western Europe 2.84 2.31-3.50 <0.0001
VKA/NOAC ratio at discharge by region
Regional differences in OAC use
Northern Europe: Denmark, Estonia, Latvia, Norway, UK; Western Europe: Belgium, France, Germany, Netherlands, Switzerland;Eastern Europe: Bulgaria, Czech Republic, Georgia, Kazakhstan, Kyrgyzstan, Poland, Romania, Russia; Southern Europe: Albania, FYR Macedonia, Italy, Malta, Montenegro, Portugal, Serbia, Spain, Turkey.
CONCLUSIONS
• The overall use of OAC for stroke prevention in Europe is relatively high and still increasing, but is driven by other factors in addition to conventional stroke risk factors.
• The use of NOACs is rapidly increasing, especially in Northern and Western Europe.
• There are substantial regional differences in the OAC use in various AF populations among European countries.
• The overall management of AF patients at risk of stroke needs further improvement.
The National Coordinator for Greece:Vassilios P. Vassilikos, MD, FACC, FESCProfessor in CardiologyMedical School, Aristotle University of Thessaloniki
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Paroxysmal Persistent LS-persistent Not defined
Pilot Long Term
AF clinical type in the EORP-AF Ablation Registries
1Arbelo E, et al. Europace 2012;14:1094–1103: 2Arbelo E, et al. Eur Heart J 2017; 38:1303–1316.
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