Br J Cardiol 2013;20:92-93 Leave a comment
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First published online August 30th 2013

Dr James Rosengarten reports highlights from the European Heart Rhythm Association (EHRA) Europace 2013 meeting held recently in Athens, Greece.

Data on the trends in management of patients with AF in five European countries were presented in a Late Breaking Clinical Trials session at the meeting. PREFER AF (Prevention of Thromboembolic Events –European Registry in Atrial Fibrillation) found that oral anticoagulation is now used in over 85% of patients with AF eligible for therapy.
PREFER AF provides a ‘snapshot’ of clinical practice across five European countries taken in 2012. It revealed that NOACs are now used by 6.1% of AF patients and that use of rhythm control interventions and catheter ablations have increased.

“PREFER AF illustrates changes in management of patients with AF since the last ESC guidelines. The registry shows that oral anticoagulant therapy is now much more widely used than in the German Competence Network on Atrial Fibrillation (AFNET) and the Euro Heart Survey registries on AF and suggests that European clinicians are using guidelines well. The rapid uptake of new oral anticoagulants suggests that these drugs are filling a therapeutic gap,” said Professor Paulus Kirchhof (School of Clinical and Experimental Medicine, University of Birmingham).

The investigators believe the study represents the largest European registry on AF to date. The ESC guidelines for the management of AF, published in 2010, incorporated several ‘evolutionary’ changes in the management of AF. These included the concept of active AF screening to initiate therapy before complications had occurred and, furthermore, emphasised that continuous oral anticoagulation was indicated for the majority of AF patients since almost all are at increased risk of stroke.

Between January 2012 and January 2013, the PREFER AF registry enrolled consecutive patients with AF from 461 centres in France, Germany, Italy, Spain and UK. Altogether 42% of patients were office based and 53% hospital based, with 89% treated by cardiologists. “Since practice patterns can be influenced by the type of physicians, we felt it was important to recruit patients from a number of different settings,” said Professor A Kirchhof.
Results showed that of the 7,243 evaluable patients enrolled, 30% had paroxysmal AF, 24% persistent AF, 7.2% long-standing persistent AF, and 38.8% had permanent AF.

When medications were examined it was found that 66.3% of patients (4,799) received a VKA as monotherapy; 9.9% of patients (720) received VKA and an antiplatelet agent in combination; and 6.1% received NOACs (dabigatran, rivaroxaban or apixaban). Furthermore, antiplatelet agents alone were given to 11.2% of patients (808) while 6.5% of patients (474) received no antithrombotic therapy at all. Altogether, 78.6% of patients were adequately rate controlled, using a mean heart rate of 60 to 100 bpm as the definition.

Rhythm control therapy was deployed in 66.7% of patients, consisting of DC cardioversion in 18.1% of patients; pharmacological conversion in 19.5%; amiodarone in 24.1%; flecainide in 10.5%; sotalol in 5.5%; dronedarone in 4.0%; other antiarrhythmic drugs in 3.1%; and catheter ablation in 5.0%.

Over 80% of patients still suffered from AF symptoms despite good rate control.

“We were surprised and puzzled by the high number of patients who suffer from AF despite good rate control,” said Professor Kirchhof. “This indicates that we have more work to do to develop tools to better prevent AF and possibly to better maintain sinus rhythm in the future.” The ongoing EAST (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial) study ( is currently testing whether early use of rhythm control therapy can prevent adverse cardiovascular outcomes in patients with AF compared to usual care.

James Rosengarten
Wessex Electrophysiology Fellow and BJCA Deanery Representative