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Prevalence of atrial fibrillation and stroke risk assessment based on telemedicine screening tools in a primary healthcare setting

      Highlights

      • Prevalence of atrial fibrillation in Brazil is expected to increase in coming years.
      • Telemedicine screening tools are critical to early detection of this disease.
      • Current use of antiarrhythmic drugs and oral anticoagulation is suboptimal.

      Abstract

      Background

      Worldwide atrial fibrillation (AF) prevalence varies between 0.1% and 4.0%, and has been increasing. Little is known about the prevalence of AF in Brazil. Our objective was to estimate the prevalence of AF in several regions of Brazil using recordings of long-distance electrocardiogram (ECG) transmission.

      Methods

      Patients from 125 outpatient general practitioner units covered by the telemedicine service of the Federal University of São Paulo were included. Only one ECG was considered per patient. A scripted telephone interview was also performed. We analyzed the data to project the prevalence of AF in the Brazilian population and estimate it for the year 2025. The overall AF prevalence was calculated based on ECGs from primary care units where patients went for routine visits.

      Results

      Based on 676,621 ECG exams from January 2009 through April 2016, the mean age (±SD) of patients was 51.38 (±19.05) years, with 57.5% being female. The 7-year period prevalence of AF was 2.2% (n = 14,968). The prevalence of AF countrywide was projected to be 1.5% in 2016 and 1.7% in 2025. In the subset of patients with AF who were interviewed (n = 301), 91 (30.2%) were not receiving any type of treatment for rate or rhythm control. Among patients interviewed, 189 (62.8%) were at high risk for stroke; only 28 (14.8%) were regular oral anticoagulant users.

      Conclusions

      Our study highlights the importance of screening for AF in the primary care setting in Brazil and identifies important gaps in the treatment of AF in this population.

      Keywords

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      References

        • Lip G.Y.H.
        • Brechin C.M.
        • Lane D.A.
        The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe.
        Chest. 2012; 142: 1489-1498
        • Chugh S.S.
        • Havmoeller R.
        • Narayanan K.
        • et al.
        Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 study.
        Circ. 2014; 129: 837-847
        • Ball J.
        • Carrington M.J.
        • McMurray J.J.V.
        • Stewart S.
        Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century.
        Int J Cardiol. 2013; 167: 1807-1824
        • Zoni-Berisso M.
        • Lercari F.
        • Carazza T.
        • Domenicucci S.
        Epidemiology of atrial fibrillation: European perspective.
        Clin Epidemiol. 2014; 6: 213-220
        • Cubillos L.
        • Haddad A.
        • Kuznik A.
        • Mould-Quevedo J.
        Burden of disease from atrial fibrillation in adults from seven countries in Latin America.
        Int J Gen Med. 2014; 7441448
        • Steinberg B.A.
        • Kim S.
        • Thomas L.
        • et al.
        Lack of concordance between empirical scores and physician assessments of stroke and bleeding risk in atrial fibrillation: results from the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF) registry.
        Circ. 2014; 129: 2005-2012
        • Wyse D.G.
        • Waldo A.L.
        • DiMarco J.P.
        • et al.
        A comparison of rate control and rhythm control in patients with atrial fibrillation.
        N Engl J Med. 2002; 347: 1825-1833
        • Hagens V.E.
        • Ranchor A.V.
        • Van Sonderen E.
        • et al.
        Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the rate control versus electrical cardioversion (RACE) study.
        J Am Coll Cardiol. 2004; 43: 241-247
        • Carlsson J.
        • Miketic S.
        • Windeler J.
        • et al.
        Randomized trial of rate-control versus rhythmcontrol in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study.
        J Am Coll Cardiol. 2003; 41: 1690-1696
        • Hohnloser S.H.
        • Kuck K.H.
        • Lilienthal J.
        Rhythm or rate control in atrial fibrillation— Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial.
        Lancet. 2000; 356: 1789-1794
        • Saúde Mais
        Direito de Todos. Diretrizes Estratégicas.
        (Available from:)
        • Instituto Brasileiro de Geografia e Estatística
        Projeção da população, Nota técnica.
        (Available from:)
        • Lip G.Y.H.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.J.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factorbased approach: the Euro Heart Survey on atrial fibrillation.
        Chest. 2010; 137263272
        • Friberg L.
        • Rosenqvist M.
        • Lip G.Y.H.
        Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study.
        Eur Heart J. 2012; 33: 1500-1510
        • Gage B.F.
        • van Walraven C.
        • Pearce L.
        • et al.
        Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin.
        Circ. 2004; 110: 2287-2292
        • Guo Y.
        • Tian Y.
        • Wang H.
        • Si Q.
        • Wang Y.
        • Lip G.Y.H.
        Prevalence, incidence, and lifetime risk of atrial fibrillation in China.
        Chest. 2015; 147: 109-119
        • Haim M.
        • Hoshen M.
        • Reges O.
        • et al.
        Prospective national study of the prevalence, incidence, management and outcome of a large contemporary cohort of patients with incident non-valvular atrial fibrillation.
        J Am Heart Assoc. 2015; 4e001486
        • Gómez-Doblas J.J.
        • Muñiz J.
        • Martin J.J.A.
        • et al.
        Prevalencia de fibrilación auricular en España. Resultados del estudio OFRECE.
        Rev Esp Cardiol. 2014; 67: 259-269
        • Colilla S.
        • Crow A.
        • Petkun W.
        • Singer D.E.
        • Simon T.
        • Liu X.
        Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population.
        Am J Cardiol. 2013; 112: 1142-1147
        • Renoux C.
        • Patenaude V.
        • Suissa S.
        Incidence, mortality, and sex differences of nonvalvular atrial fibrillation: a population-based study.
        J Am Heart Assoc. 2014; 3e001402
        • Marcolino M.S.
        • Palhares D.M.F.
        • Benjamin E.J.
        • Ribeiro A.L.
        Atrial fibrillation: prevalence in a large database of primary care patients in Brazil.
        Europace. 2015; 17: 1787-1790
        • Wilke T.
        • Groth A.
        • Mueller S.
        • et al.
        Incidence and prevalence of atrial fibrillation: an analysis based on 8.3 million patients.
        Europace. 2013; 15: 486-493
        • Clua-Espuny J.L.
        • Lechuga-Duran I.
        • Bosch-Princep R.
        • et al.
        Prevalence of undiagnosed atrial fibrillation and of that not being treated with anticoagulant drugs: the AFABE study.
        Rev Esp Cardiol (Engl Ed). 2013; 66: 545-552
        • Mars M.
        Telemedicine and advances in urban and rural healthcare delivery in Africa.
        Prog Cardiovasc Dis. 2013; 56: 326-335
        • Alkmim M.B.
        • Figueira R.M.
        • Marcolino M.S.
        • et al.
        Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil.
        Bull World Health Organ. 2012; 90: 373-378
        • Kirchhof P.
        • Benussi S.
        • Kotecha D.
        • et al.
        ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC, endorsed by the European Stroke Organisation (ESO).
        Eur Heart J 2016. 2016; 37: 2893-2962
        • Mairesse G.H.
        • Moran P.
        • Van Gelder I.C.
        • et al.
        ESC Scientific Document Group; screening for atrial fibrillation: a European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología (SOLAECE).
        EP Europace. 2017; 10: 1589-1623
        • Kakkar A.K.
        • Mueller I.
        • Bassand J.-P.
        • et al.
        Risk profiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke: perspectives from the international, observational, prospective GARFIELD registry.
        PLoS One. 2013; 8e63479
        • Huisman M.V.
        • Rothman K.J.
        • Paquette M.
        • et al.
        Antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation: the GLORIA-AF registry, phase II.
        Am J Med. 2015; 128: 1306-1313.e1
        • Lopes R.D.
        • de Paola A.A.V.
        • Lorga Filho A.M.
        • et al.
        Rationale and design of the first Brazilian cardiovascular registry of atrial fibrillation: the RECALL study.
        Am Heart J. 2016; 176: 10-16
        • Boriani G.
        • Proietti M.
        • Laroche C.
        • et al.
        Contemporary stroke prevention strategies in 11096 European patients with atrial fibrillation: a report from the EURObservational research Programme on Atrial Fibrillation (EORP-AF) long-term general registry.
        Europace. 2018; 20: 747-757
        • Kirchhof P.
        • Ammentorp B.
        • Darius H.
        • et al.
        Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events--European Registry in Atrial Fibrillation (PREFER in AF).
        Europace. 2014; 16: 6-14
        • Steinberg B.A.
        • Holmes D.N.
        • Ezekowitz M.D.
        • et al.
        Rate versus rhythm control for management of atrial fibrillation in clinical practice: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry.
        Am Heart J. 2013; 165: 622-629
        • Oldgren J.
        • Healey J.S.
        • Ezekowitz M.
        • et al.
        Variations in cause and management of atrial fibrillation in a prospective registry of 15,400 emergency department patients in 46 countries: the RE-LY Atrial Fibrillation Registry.
        Circ. 2014; 129: 1568-1576
        • Magalhães L.
        • Figueiredo M.
        • Cintra F.
        • et al.
        II Diretrizes Brasileiras de Fibrilação Atrial.
        Arq Bras Cardiol. 2016; 106: 1-22
        • Vinereanu D.
        • Lopes R.D.
        • Bahit M.C.
        • et al.
        A multifaceted intervention to improve treatment with oral anticoagulants in atrial fibrillation (IMPACT-AF): an international, cluster-randomised trial.
        Lancet. 2017; 390: 1737-1746
        • Alexander J.H.
        • Lopes R.D.
        • Thomas L.
        • et al.
        Apixaban vs. warfarin with concomitant aspirin in patients with atrial fibrillation: insights from the ARISTOTLE trial.
        Eur Heart J. 2014; 35: 224-232
        • Fornari L.S.
        • Calderaro D.
        • Nassar I.B.
        • et al.
        Misuse of antithrombotic therapy in atrial fibrillation patients: frequent, pervasive and persistent.
        J Thromb Thrombolysis. 2007; 23: 65-71
        • Massaro A.R.
        • Lip G.Y.H.
        • Massaro A.R.
        • Lip G.Y.H.
        Stroke prevention in atrial fibrillation: focus on Latin America.
        Arq Bras Cardiol. 2016; 107: 576-589
        • Hylek E.M.
        • D'Antonio J.
        • Evans-Molina C.
        • et al.
        Translating the results of randomized trials into clinical practice: the challenge of warfarin candidacy among hospitalized elderly patients with atrial fibrillation.
        Stroke. 2006; 37: 1075-1080
        • Matos L.N.
        • Gonçalves I.
        • Moraes E.
        • et al.
        Are emergency cardiologic cases originating from ambulance calls different from light ER outposts? Analysis of 64002 pre-hospital ECGs [abstract]. ESC Congress 2011, Paris, August 29.
        Eur Heart J. 2011; 32: 348-349

      Linked Article

      • Screening for atrial fibrillation: Need for an integrated, structured approach
        European Journal of Internal MedicineVol. 67
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          Atrial fibrillation (AF) is a very common disease, particularly in the elderly, and the number of affected patients has been predicted to increase in the next decades [1,2]. The existence of a link between AF and ischemic stroke is now well established, with AF being present in around 30% of patients reporting an ischemic stroke, as well as with stroke being the first clinical manifestation of previously unknown AF in over 25% of AF-related strokes [3].
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