ClinicalAtrial FibrillationPatterns of care for first-detected atrial fibrillation: Insights from the Get With The Guidelines® – Atrial Fibrillation registry
Graphical abstract
Introduction
Atrial fibrillation (AF) is a common arrhythmia and accounts for >450,000 hospitalizations each year in the United States.1 AF is associated with substantial morbidity (stroke, cognitive decline, and heart failure), mortality, and health care expenditures.2,3 The prevalence of AF continues to increase and outpace projections.4 In most patients, with recurrent episodes and atrial remodeling, there is usually a progression from paroxysmal to persistent forms of AF.5, 6, 7 While rate control with pharmacotherapy aims at symptomatic improvement related to rapid ventricular rates, rhythm control with antiarrhythmic drugs, cardioversion, or ablation targets the maintenance of sinus rhythm, which can potentially halt the progression of AF to more persistent forms. There is increased interest in the treatment of first-detected AF as time from diagnosis has been identified as an important prognostic marker in AF.8, 9, 10, 11 However, the optimal management of patients with an initial episode of AF remains unclear.
Previous trials that compared rhythm and rate control strategies in patients with AF failed to demonstrate the superiority of rhythm control in patient outcomes, symptom control, morbidity, or mortality.12, 13, 14 It should be noted that the success of maintaining sinus rhythm in the cardioversion arms was low at <25% in some of these trials.12,13 However, a contemporary randomized controlled trial demonstrated improved cardiovascular outcomes with early rhythm control (compared with usual care) in patients with a diagnosis of AF in the past year and concomitant cardiovascular risk factors (The Early Treatment of Atrial Fibrillation for Stroke Prevention Trial).15
Data for managing patients with their first episode of AF (first-detected AF) is still lacking. Accordingly, we sought to analyze contemporary patterns of care and treatment strategies in patients hospitalized with an initial episode of AF, examine specific types of rhythm control strategies, and identify predictors associated with the choice of rhythm over rate control in the American Heart Association/American Stroke Association’s Get With the Guidelines® – Atrial Fibrillation (GWTG-AFIB) registry.
Section snippets
Data source
This study used data accrued through the GWTG-AFIB registry, an ongoing national, voluntary, prospective quality improvement initiative that was started by the American Heart Association/American Stroke Association in partnership with the Heart Rhythm Society in 2013. The registry’s design, goals, objectives, and data elements have been well described previously.16 The GWTG-AFIB registry collects data on patient demographic characteristics, medical history, in-hospital care, discharge
Baseline characteristics—Overall cohort
Between January 1, 2013, and June 30, 2019, 86,759 patients with AF were identified from 161 sites. Among this population, 15,473 patients (17.8%) were diagnosed with first-detected AF at 140 sites. After excluding patients with the following predetermined criteria—patients missing AF management strategy (2681 patients); patients with comfort measures only (516 patients); patients discharged to hospice, died, or missing destination information (302 patients); patients with sinus rhythm on
Discussion
Emerging evidence suggests that early initiation of rhythm control improves outcomes, yet little is known about how first-detected AF is approached in clinical practice.8,15 In this analysis of >11,000 patients presenting with new-onset AF in the GWTG-AFIB registry, there were 3 major findings. First, <50% of patients were planned for rhythm control. Second, patients with planned rhythm control had a shorter length of stay, higher rates of being discharged home, and higher rates of being
Conclusion
Our study presents a snapshot of the contemporary management practices for first-detected AF. Early rhythm control has been shown to arrest the progression of AF and improve patient outcomes; in this analysis, rhythm control was effective in maintaining sinus rhythm at discharge in ∼73% of patients compared with 34% for intended rate control. Further, patients with intended rhythm control had a higher likelihood of a shorter length of stay, of being discharged home, and of being discharged on
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Funding Sources: The Get With the Guidelines® – Atrial Fibrillation (GWTG-AFIB) program is provided by the American Heart Association. GWTG-AFIB is sponsored, in part, by Novartis and BMS-Pfizer.
Disclosures: Dr Fonarow reports consulting for Abbott, Amgen, AstraZeneca, Bayer, Cytokinetics, Edwards, Janssen, Medtronic, Merck, and Novartis. Dr Piccini reports consulting for Abbott, AbbVie, AltaThera, ARCA Biopharma, Biotronik, Boston Scientific, ElectroPhysiology Frontiers, LivaNorta, Medtronic, Milestone, MyoKardia, Pfizer, Philips, Sanofi, and UptoDate. Dr Desai reports consulting for Amgen, Boehringer Ingelheim, Cytokinetics, Relypsa, and Novartis and receives research funding from the Centers for Medicare and Medicaid Services to develop and maintain performance measures that are used for public reporting. The rest of the authors report no conflicts of interest.