Cardiac troponins and adverse outcomes in European patients with atrial fibrillation: A report from the ESC-EHRA EORP atrial fibrillation general long-term registry

Cardiac troponins (cTn) are the preferred biomarkers for the detection of myocardial injury and the diagnosis of myocardial infarction (MI) [, , ]. However, with the advent of high-sensitivity (hs)-cTn assays, elevated levels of cTn may be a common finding in daily clinical practice even in several non-ischaemic, acute or chronic conditions, such as heart failure (HF), chronic kidney disease (CKD), sepsis, inflammatory diseases, etc. [, , , , , , ].

In the last decades, several biomarkers have emerged as significant predictors for adverse outcomes in atrial fibrillation (AF) patients [, , , ]. As for the other clinical conditions reported above, independent of the specific assay used, cTn elevations may be detected in AF patients with or without overt coronary artery disease (CAD) [,]. Additionally, elevated levels of cTn have been found to be independent predictors of AF in the general population [,]. Despite the increasing number of studies investigating biomarkers in AF, including cTn, their value in daily clinical practice and routine risk prediction is still debated [, , , ]. Since most of the studies available were based on a highly selected populations from randomized controlled trials (RCTs), [, , ] data on real-world AF patients are limited.

Accordingly, the aim of this study was to assess the factors associated with cTn testing in routine clinical practice and evaluate the association of elevated levels of cTn with adverse outcomes in a large contemporary cohort of AF patients from the European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Atrial Fibrillation General Long-Term Registry.

Among the 11,096 AF patients originally enrolled into the ESC-EHRA EORP Atrial Fibrillation General Long-Term Registry, a total of 10,445 (94.1%) patients with available data on cTn measurement and follow-up status at 2-years were included in this analysis. Cardiac troponins were tested in 2834 (27.1%) being elevated in 904/2834 (31.9%) and in-range in 1930/2834 (68.1%) patients

Median (IQR) age was 71 (63–77) years, 40.3% were female and overall, the median (IQR) CHA₂DS₂VASc and HASBLED score were 3 (2–4) and 1 (1–2), respectively. Baseline characteristics according to cTn testing are shown in Tables 1 and S1 (Supplementary materials).

Patients in whom cTn was elevated tended to be older (p < 0.001), more frequently enrolled in a hospital setting (p <0.001) with significantly higher baseline CHA₂DS₂VASc and HASBLED scores (p < 0.001) (Table 1).

There was a significant association between the measurement of cTn and symptomatic status at admission/consultation. EHRA score was higher in patients in those where cTn was tested (median 2 (1-2) vs 2 (1–3), p < 0.001) as well as the presence of atypical AF-related symptoms (i.e. chest pain, dyspnea or syncope) (Tables 1 and S1). Diabetes mellitus, current smoking and physical inactivity were reported less frequently in patients without a cTn assessment (all p < 0.001). Heart failure, previous CAD, peripheral vascular disease, anemia, CKD and malignancy were more prevalent in patients with elevated cTn (Table 1). AF was the main reason for admission or consultation in two-thirds (66.6%). Other reasons for admission or consultation included HF (10%), valvular heart disease (2.8%), hypertension (2.1%) and others CV and non-CV reasons in the remaining cases. Only 3.4% had a suspected ACS at admission/consultation, whereas a diagnosis of ACS was confirmed in 215 patients (2.1%) at discharge.

Pharmacological treatments, including antithrombotic patterns, and cardiac interventions performed during the admission/consultation are shown in Table S2. Overall, non-vitamin K antagonist OACs (NOACs) were prescribed in 3340 (32.0%) while 4303 (41.2%) patients received vitamin K antagonists (VKA). Patients with cTn tested were more frequently treated with OAC with concomitant antiplatelet(s) (p < 0.001) (Table S2).

Overall, myocardial revascularization (either PCI or CABG) were performed in 245/10,445 (2.3%) patients with a significant higher occurrence in patients with elevated cTn compared with patients without cTn testing or those with cTn in range (12.2% vs 1.0% vs 3.0%, p < 0.001) (Table S2).

The principal findings of this analysis based on the EORP-AF General Long-Term Registry are: (i) cTn was assessed in more than a quarter of AF patients enrolled; (ii) overall, clinical factors that might enhance the need to rule out an underlying ACS, such as presence of atypical AF-related symptoms, previous history of CAD and first detected AF were independently associated with cTn measurement in daily clinical practice; and (iii) AF patients with elevated cTn levels had a significant independent increased risk for CV adverse events, all-cause mortality, hemorrhagic events and hospital readmissions, even after the exclusion of patients with CAD or history of CAD.

To the best of our knowledge, the present study represents one of the largest analysis assessing the current use, as well as the prognostic implications, of cTn measurement in unselected AF patients and had the advantage of exploring AF management in the “real world”. The present analysis offers a “real-world” snapshot on unselected AF patients showing that cTn testing is common in daily clinical practice and provides new insights in the possible diagnostic and predictive implications of cTn measurement in such patients. Indeed, a reasonable application of biomarkers, according to clinical judgment and patient profile, appears to support clinical-decision making at first patient assessment, but may also integrate outcome prediction and clinical risk stratification. However, cTn should be considered only in selected AF patients since inappropriate use or interpretation of cTn, could results in unnecessary and even harmful procedures, and a waste of healthcare resources.

It is noteworthy that at the time of data collection (2013–2016) no specific indications for measuring cTn were included in the guidelines for the management of AF []. Even later, the role of cTn has remained undefined, with some indications for improving risk stratification for stroke and bleeding, apart the expected (and more established) role of ruling out cardiac ischemia [, , ]. Our analysis highlights that the practice of use of cTn is variable, with a wider use in some geographical regions and contexts. In interpreting this heterogeneity, both the variability in local protocols and habits, as well as regional differences in patient characteristics, and management options, should be considered, as previously suggested by other analysis from the EORP-AF Pilot registry [].

In the literature, the use of cTn is variable, even in the context of assessment of patients presenting with chest pain []. This variability may involve patients presenting with AF, especially patients presenting at emergency departments (ED), where the use of cTn evaluation may differ among countries in quantitative terms, as well as in terms of clinical guidance [,]. In view of the variable positive predictive accuracy for cardiac ischemia according to patient selection, it appears appropriate, according to our findings, to better define the indications for using cTn, either in terms of diagnostic testing and separately, to risk stratify patient outcomes.

The first part on our analysis focused on describing how frequently cTn was tested in general AF patients and which clinical variables could drive the clinician to proceed with such measurements.

As expected, most of the cTn assessments were performed in hospitalized AF patients. Nevertheless, since our registry enrolled both in and out-patients, it was quite surprising that 16% of cTn tests were performed during regular out-patient clinic consultations and theoretically, in stable AF patients, with significant differences among European countries that could reflect differences in habits, protocols or characteristics of healthcare systems [,]. In the “real world”, cTn testing may be frequent even in the absence of symptoms or clinical presentation suggestive of CAD or ACS [,,] and in this setting the most recent guidelines take into consideration a potential role in refining risk stratification for stroke or bleeding [,].

In a large retrospective study of emergency department (ED) visits from the National Hospital Ambulatory Medical Care Survey in the United States, cardiac biomarkers were tested in 8.2% (95% CI, 7.1–9.5%) of visits in the absence of ACS-related symptoms []. Of note, more than a quarter of all visits with cardiac biomarker testing did not have an electrocardiogram recorded which should be one of the first diagnostic tests in patients with suspected ACS [,]. These data further confirm that in some settings cTn may be widely used in the ED, as a first line routine assessment, even before a full clinical evaluation [].

We also investigated the factors associated with troponin testing. The main reasons why clinicians performed cTn testing in AF patients were mostly related to a suspicion of underlying ACS, both in hospitalized and outpatient clinic setting. Indeed, atypical AF-related symptoms (such as chest pain, dyspnea or syncope), first detected AF, history of CAD or CV risk factors such as smoking or physical inactivity, were independent predictors of cTn testing. The findings that atypical AF-related symptoms were significantly associated with cTn testing may be justified either by the need to rule-out cardiac ischemia, or by the fact that atypical AF clinical presentation seems to be associated with less favourable outcome. As reported, AF patients presenting with atypical symptoms had higher rates of cerebrovascular events and mortality compared to patients with typical presentation even after adjustment for the CHA₂DS₂-VASc score, comorbidities, and OAC therapy [].

In the recent years, it has been discussion over whether elevated levels of cTn in AF patients, either symptomatic or asymptomatic, could indicate the presence of masked CAD, cardiac ischemia or myocardial injury. In daily clinical practice, cardiac biomarkers are often tested in patients with AF presenting to the hospital, especially in patients with new onset AF, to rule out an underlying ACS. However, the use of cTn in this setting and its predictive value to detected significant CAD, are not well established [,,]. Recent results from the Troponins in Atrial Fibrillation study (The Tropo-AF Study) found that AF patients presenting to the ED had often minor cTn elevation related to non-ischaemic causes (such as infections, cerebrovascular events, HF, bone fractures, chronic kidney disease etc) []. Different mechanisms have been proposed to explain the release of cTn during AF. Indeed, masked CAD may be just one of the cause of cTn elevation in AF patients, since AF itself, as any other supraventricular tachycardia, may cause cTn elevation in the absence of significant underlying heart disease due only to the high ventricular heart rate. A recent retrospective Finnish study, investigated the association of heart rate with hs-cTnT levels in patients admitted to the ED for AF, finding that high ventricular heart rate was significantly related with troponin release with a nonlinear association that became evident only above the heart rate threshold of 125 bpm [].

In support of these results, the Rate Control in Atrial Fibrillation (RATAF) trial found that cTn was detectable even in stable patients with permanent AF, preserved left ventricular ejection fraction and without ischemic heart disease or HF and a moderate reduction of heart rate by beta-blockers and calcium channel blockers, was significantly associated with lower cTn levels []. Other known mechanisms of cTn release in AF patients, include high atrial rates, reduced ventricular perfusion during AF, cell injury, apoptosis, myocardial strain, inflammation, and acute or chronic renal impairment [,, , , ].

In our cohort, AF patients with elevated cTn levels had a significant independent higher risk of all cause-death and MACE. These findings integrate and extend to the “real-world” setting the results of different sub-analyses focused on cardiac biomarkers of the pivotal RCTs on NOACs, performed in highly selected patients [, , ,]. Our analysis actually expands the implications for the outcomes of elevated cTn levels highlighted by these studies performed in selected trial populations. It is noteworthy that we found similar results even after excluding those AF patients with various form of CAD, thus empathizing the negative prognostic impact of elevated levels of cTn, independent of a known history of CAD.

Although the present analyses were adjusted for CHA₂DS₂-VASc score and presence of comorbidities, the association between AF and coronary events could also be justified by the similar risk factors and pathophysiological processes such as inflammation, prothrombotic state, endothelial dysfunction etc., shared by AF and CAD patients [,]. In a study by Conti et al., the relationship between of coronary atherosclerosis and adverse outcomes was analyzed using troponin levels rises in more than 3500 recent-onset AF patients without severe comorbidities []. Patients with a recent-onset AF and a troponin rise had significantly increased risk of adverse coronary events when compared with patients without troponin rise (19% vs 1%) and during a 5-year follow-up almost 50% of the patients with a troponin rise underwent coronary revascularization [].

In consideration of the observational nature of our study and available data, we were able to simply stratify our cohort between patients with normal or elevated plasma cTn levels, but we were not able to investigate differences in outcome across specific ranges of elevated cTn values. Serial troponins were not tested in some patients and in some cases our results were based on a single cTn determination. We could not determinate a “rise and fall” or temporal pattern of cTn release that is used to rule out ACS. However, our aim was to evaluate if even one cTn assessment could have prognostic implications independently from the diagnosis of myocardial infarction in a general AF population. It has been reported that any abnormally elevated cTn at any level were associated with adverse outcomes [,,]. Even a single elevated cTn value at presentation indicates an increased risk of adverse clinical outcomes (e.g. all-cause or cardiovascular death) in different patient populations (including those without acute ischemic conditions) []. This was confirmed by the additional subanalysis that we performed excluding patients with ACS or CAD in whom elevated cTn were still significantly associated with adverse outcomes. Of note, our study actually reflects what frequently occurs in clinical practice where troponin levels are often dichotomized into “positive” (i.e. >99th percentile of the upper limit of normal for the cTn assay) or “negative”.

Finally our study also showed that patients with cTn tested in range were associated with higher occurrence of adverse events during follow-up. Given the observational nature of the study, our findings have to be interpreted in terms of associations, and may be affected by confounding. We can hypothesize that the patient clinical profile that let physicians to test for cTn may imply some additional risk of bleeding or hospital re-admission, to explain the associations found.

In this large contemporary cohort of European AF patients a clinical presentation or baseline characteristics that might enhance the need to rule out an underlying ACS, such as presence of atypical AF-related symptoms, previous history of CAD and first detected AF were independently associated with cTn measurement in daily clinical practice. Elevated levels of cTn were independently associated with an increased risk of all-cause mortality and adverse CV events, including hospital readmissions, even after exclusion of patients with CAD or history of CAD.

Since the start of EORP, the following companies have supported the program: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2016), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2011–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2017), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), SERVIER (2010–2021), and Vifor (2019–2022).

The data underlying this article were provided by the European Society of Cardiology by permission. Data will be shared on request to the corresponding author with permission of ESC Editorial is also expected but not yet confirmed.

EORP Oversight Committee, Executive and Steering Committees (National Coordinators) of the EURObservational Research Program (EORP)—Atrial Fibrillation General Long-Term (EORP- AFGen LT) Registry of the European Society of Cardiology (ESC). Data collection was conducted by the EORP department by Patti- Ann McNeill as Project Officer, Viviane Missiamenou as Data Manager. Overall activities were coordinated and supervised by Doctor Aldo P. Maggioni (EORP Scientific Coordinator).

Executive committee: G.Boriani (Chair), G.Y.H. Lip, L. Tavazzi, A. P. Maggioni, G-A. Dan, T. Potpara, M. Nabauer, F. Marin, Z. Kalarus, L. Fauchier.

Steering Committee (National Coordinators): A. Goda, University Hospital Center "Mother Tereza", Tirana, Albania; G. Mairesse, Cliniques du Sud-Luxembourg, Arlon, Belgium; T. Shalganov, National Heart Hospital, Sofia, Bulgaria; L. Antoniades, Nicosia General Hospital, Latsia, Cyprus; M. Taborsky, University Hospital Olomouc, Olomouc, Czech Republic; S. Riahi, Aalborg University Hospital, Aalborg, Denmark; P. Muda, University of Tartu, Tartu, Estonia; I. García Bolao, Navarra Institute for Health Research, Pamplona, Spain; O. Piot, Center Cardiologique du Nord, Saint-Denis, France; M. Nabauer, Ludwig-Maximilians-University, Munich, Germany; K. Etsadashvili, G. Chapidze Emergency Cardiology Center, Tbilisi, Georgia; EN. Simantirakis, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece; M. Haim, Soroka Medical Center, Beer Sheva, Israel; A. Azhari, J. Najafian, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran; M. Santini, San Filippo Neri Hospital, Rome, Italy; E. Mirrakhimov, National Center of Cardiology and Internal Medicine, Bishkek, Kyrgyzstan; K. Kulzida, Scientific-Research Institute of Cardiology and Internal Diseases, Almaty, Republic of Kazakhstan; A. Erglis, Pauls Stradins Clinical University Hospital University of Latvia Riga Latvia; L. Poposka, University Clinic of Cardiology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia; MR. Burg, Mater Dei Hospital, Triq Dun Karm Psaila, Malta; H. Crijns, Ö. Erküner, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands; D. Atar, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway; R. Lenarczyk, Silesian Center for Heart Disease, Zabrze, Poland; M. Martins Oliveira, Hospital Santa Marta, Lisbon, Portugal; D. Shah, Department of Medicine Specialities, University Hospital Geneva, Geneva, Switzerland; G-A. Dan, Colentina University Hospital, Bucharest, Romania; E. Serdechnaya, Northern State Medical University, Arkhangelsk, Russia; T. Potpara, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia; E. Diker, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey; G.Y.H. Lip, D. Lane; City Hospital, University of Birmingham, Birmingham, United Kingdom.

Participants: ALBANIA Durrës: E. Zëra, Tirana: U. Ekmekçiu, V. Paparisto, M. Tase, Tirana: H. Gjergo, J. Dragoti, A. Goda, BELGIUM Bastogne: M. Ciutea, N. Ahadi, Z. el Husseini, M. Raepers, Gilly: J. Leroy, P. Haushan, A. Jourdan, Haine Saint Paul: C. Lepiece, Hasselt: L. Desteghe, J. Vijgen, P. Koopman, G. Van Genechten, H. Heidbuchel, Kortrijk: T. Boussy, M. De Coninck, H. Van Eeckhoutte, N. Bouckaert, La Louviere: A. Friart, J. Boreux, C. Arend, Liege: P. Evrard, Liège: L. Stefan, E. Hoffer, J. Herzet, M. Massoz, Liège: C. Celentano, M. Sprynger, L. Pierard, Liège: P. Melon, Overpelt: B. Van Hauwaert, C. Kuppens, D. Faes, D. Van Lier, A. Van Dorpe, Waremme: A. Gerardy, Yvoir: O. Deceuninck, O. Xhaet, F. Dormal, E. Ballant, D. Blommaert, BULGARIA Pleven: D. Yakova, M. Hristov, T. Yncheva, N. Stancheva, S. Tisheva, Plovdiv: M. Tokmakova, F. Nikolov, D. Gencheva, Sofia: T. Shalganov, B. Kunev, M. Stoyanov, Sofia: D. Marchov, V. Gelev, V. Traykov, Varna: A. Kisheva, H. Tsvyatkov, R. Shtereva, S. Bakalska-Georgieva, S. Slavcheva, Y. Yotov, CZECH REPUBLIC Ústí nad Labem: M. Kubíčková, DENMARK Aalborg: A. Marni Joensen, A. Gammelmark, L. Hvilsted Rasmussen, P. Dinesen, S. Riahi, S. Krogh Venø, B. Sorensen, A. Korsgaard, K. Andersen, C. Fragtrup Hellum, Esbjerg: A. Svenningsen, O. Nyvad, P. Wiggers, Herning: O. May, A. Aarup, B. Graversen, L. Jensen, M. Andersen, M. Svejgaard, S. Vester, S. Hansen, V. Lynggaard, Madrid: M. Ciudad, Tallinn: R. Vettus, Tartu: P. Muda, ESTONIA Elche, Alicante: A. Maestre, Toledo: S. Castaño, FRANCE Abbeville: S. Cheggour, Abbeville: J. Poulard, V. Mouquet, S. Leparrée, Aix-en-Provence: J. Bouet, J. Taieb, Amiens: A. Doucy, H. Duquenne, Angers: A. Furber, J. Dupuis, J. Rautureau, Aurillac: M. Font, P. Damiano, Avignon Cedex: M. Lacrimini, Brest: J. Abalea, S. Boismal, T. Menez, J. Mansourati, Chartres: G. Range, H. Gorka, C. Laure, C. Vassalière, Creteil: N. Elbaz, N. Lellouche, K. Djouadi, Montpellier: F. Roubille, D. Dietz, J. Davy, Nimes: M. Granier, P. Winum, C. Leperchois-Jacquey, Paris: H. Kassim, E. Marijon, J. Le Heuzey, Paris: J. Fedida, C. Maupain, C. Himbert, E. Gandjbakhch, F. Hidden-Lucet, G. Duthoit, N. Badenco, T. Chastre, X. Waintraub, M. Oudihat, J. Lacoste, C. Stephan, Pau: H. Bader, N. Delarche, L. Giry, Pessac: D. Arnaud, C. Lopez, F. Boury, I. Brunello, M. Lefèvre, R. Mingam, M. Haissaguerre, Rennes: M. Le Bidan, D. Pavin, V. Le Moal, C. Leclercq, Saint Denis: O. Piot, T. Beitar, Saint Etienne: I. Martel, A. Schmid, N. Sadki, C. Romeyer-Bouchard, A. Da Costa, Tours: I. Arnault, M. Boyer, C. Piat, L. Fauchier, FYR MACEDONIA Bitola: N. Lozance, S. Nastevska, Ohrid: A. Doneva, B. Fortomaroska Milevska, B. Sheshoski, K. Petroska, N. Taneska, N. Bakrecheski, Skopje: K. Lazarovska, S. Jovevska, V. Ristovski, A. Antovski, Skopje: E. Lazarova, I. Kotlar, J. Taleski, L. Poposka, S. Kedev, Skopje: N. Zlatanovik, Štip: S. Jordanova, T. Bajraktarova Proseva, S. Doncovska, GEORGIA Tbilisi: D. Maisuradze, A. Esakia, E. Sagirashvili, K. Lartsuliani, N. Natelashvili, N. Gumberidze, R. Gvenetadze, Tbilisi: K. Etsadashvili, N. Gotonelia, N. Kuridze, Tbilisi: G. Papiashvili, I. Menabde, GERMANY Aachen: S. Glöggler, A. Napp, C. Lebherz, H. Romero, K. Schmitz, M. Berger, M. Zink, S. Köster, J. Sachse, E. Vonderhagen, G. Soiron, K. Mischke, Bad Reichenhall: R. Reith, M. Schneider, Berlin: W. Rieker, Biberach: D. Boscher, A. Taschareck, A. Beer, Boppard: D. Oster, Brandenburg: O. Ritter, J. Adamczewski, S. Walter, Chemnitz: A. Frommhold, E. Luckner, J. Richter, M. Schellner, S. Landgraf, S. Bartholome, Chemnitz: R. Naumann, J. Schoeler, Dachau: D. Westermeier, F. William, K. Wilhelm, M. Maerkl, Detmold: R. Oekinghaus, M. Denart, M. Kriete, U. Tebbe, Ebersbach: T. Scheibner, Erlangen: M. Gruber, A. Gerlach, C. Beckendorf, L. Anneken, M. Arnold, S. Lengerer, Z. Bal, C. Uecker, H. Förtsch, S. Fechner, V. Mages, Friedberg: E. Martens, H. Methe, Göttingen: T. Schmidt, Hamburg: B. Schaeffer, B. Hoffmann, J. Moser, K. Heitmann, S. Willems, S. Willems, Hartmannsdorf: C. Klaus, I. Lange, Heidelberg: M. Durak, E. Esen, Itzehoe: F. Mibach, H. Mibach, Kassel: A. Utech, Kirchzarten: M. Gabelmann, R. Stumm, V. Ländle, Koblenz: C. Gartner, C. Goerg, N. Kaul, S. Messer, D. Burkhardt, C. Sander, R. Orthen, S. Kaes, Köln: A. Baumer, F. Dodos, Königsbrück: A. Barth, G. Schaeffer, Leisnig: J. Gaertner, J. Winkler, Leverkusen: A. Fahrig, J. Aring, I. Wenzel, Limburg: S. Steiner, A. Kliesch, E. Kratz, K. Winter, P. Schneider, Ludwigsburg: A. Haag, I. Mutscher, R. Bosch, Markkleeberg: J. Taggeselle, S. Meixner, Meissen: A. Schnabel, Meppen: A. Shamalla, H. Hötz, A. Korinth, Merzig: C. Rheinert, Moosburg: G. Mehltretter, Mühldorf: B. Schön, N. Schön, A. Starflinger, E. Englmann, Munich: G. Baytok, T. Laschinger, G. Ritscher, Munich: A. Gerth, Münster: D. Dechering, L. Eckardt, Nienburg: M. Kuhlmann, N. Proskynitopoulos, Paderborn: J. Brunn, K. Foth, Pirna: C. Axthelm, H. Hohensee, K. Eberhard, S. Turbanisch, Plauen: N. Hassler, A. Koestler, Riesa: G. Stenzel, Riesa: D. Kschiwan, M. Schwefer, S. Neiner, S. Hettwer, Rotenburg a.d. Fulda: M. Haeussler-Schuchardt, R. Degenhardt, S. Sennhenn, S. Steiner, Starnberg: M. Brendel, Westerstede: A. Stoehr, W. Widjaja, S. Loehndorf, A. Logemann, J. Hoskamp, J. Grundt, Zorneding: M. Block, Zwiesel: R. Ulrych, A. Reithmeier, V. Panagopoulos, ITALY Bologna: C. Martignani, D. Bernucci, E. Fantecchi, I. Diemberger, M. Ziacchi, M. Biffi, P. Cimaglia, J. Frisoni, G. Boriani, Firenze: I. Giannini, S. Boni, S. Fumagalli, S. Pupo, A. Di Chiara, P. Mirone, Modena: E. Fantecchi, G. Boriani, F. Pesce, C. Zoccali, V.L.Malavasi, KAZAKHSTAN Almaty: A. Mussagaliyeva, B. Ahyt, Z. Salihova, K. Koshum-Bayeva, KYRGYZSTAN Bishkek: A. Kerimkulova, A. Bairamukova, E. Mirrakhimov, LATVIA Riga: B. Lurina, R. Zuzans, S. Jegere, I. Mintale, K. Kupics, K. Jubele, A. Erglis, O. Kalejs, MALTA Birkirkara: K. Vanhear, M. Burg, M. Cachia, E. Abela, S. Warwicker, T. Tabone, R. Xuereb, MONTENEGRO Podgorica: D. Asanovic, D. Drakalovic, M. Vukmirovic, N. Pavlovic, L. Music, N. Bulatovic, A. Boskovic, NETHERLANDS Almere: H. Uiterwaal, N. Bijsterveld, Amsterdam: J. De Groot, J. Neefs, N. van den Berg, F. Piersma, A. Wilde, Delfzijl: V. Hagens, Enschede: J. Van Es, J. Van Opstal, B. Van Rennes, H. Verheij, W. Breukers, Heerenveen: G. Tjeerdsma, R. Nijmeijer, D. Wegink, R. Binnema, Hengelo: S. Said, Maastricht: Ö. Erküner, S. Philippens, W. van Doorn, H. Crijns, Rotterdam: T. Szili-Torok, R. Bhagwandien, P. Janse, A. Muskens, s-Hertogenbosch: M. van Eck, R. Gevers, N. van der Ven, Venlo: A. Duygun, B. Rahel, J. Meeder, NORWAY Oslo: A. Vold, C. Holst Hansen, I. Engset, D. Atar, POLAND Bytom: B. Dyduch-Fejklowicz, E. Koba, M. Cichocka, Cieszyn: A. Sokal, A. Kubicius, E. Pruchniewicz, Gliwice: A. Kowalik-Sztylc, W. Czapla, Katowice: I. Mróz, M. Kozlowski, T. Pawlowski, M. Tendera, Katowice: A. Winiarska-Filipek, A. Fidyk, A. Slowikowski, M. Haberka, M. Lachor-Broda, M. Biedron, Z. Gasior, Kielce: M. Kołodziej, M. Janion, Kielce: I. Gorczyca-Michta, B. Wozakowska-Kaplon, Łódź: M. Stasiak, P. Jakubowski, T. Ciurus, J. Drozdz, Łódź: M. Simiera, P. Zajac, T. Wcislo, P. Zycinski, J. Kasprzak, Nysa: A. Olejnik, E. Harc-Dyl, J. Miarka, M. Pasieka, M. Ziemińska-Łuć, W. Bujak, Opoczno: A. Śliwiński, A. Grech, J. Morka, K. Petrykowska, M. Prasał, Opole: G. Hordyński, P. Feusette, P. Lipski, A. Wester, Radlin: W. Streb, Rzeszów: J. Romanek, P. Woźniak, M. Chlebuś, P. Szafarz, W. Stanik, Szczecin: M. Zakrzewski, J. Kaźmierczak, Szczecin: A. Przybylska, E. Skorek, H. Błaszczyk, M. Stępień, S. Szabowski, W. Krysiak, M. Szymańska, Tarnów: J. Karasiński, J. Blicharz, M. Skura, Warsaw: K. Hałas, L. Michalczyk, Z. Orski, K. Krzyżanowski, A. Skrobowski, Warsaw: L. Zieliński, M. Tomaszewska-Kiecana, M. Dłużniewski, Warsaw: M. Kiliszek, M. Peller, M. Budnik, P. Balsam, G. Opolski, A. Tymińska, K. Ozierański, A. Wancerz, Warsaw: A. Borowiec, E. Majos, R. Dabrowski, H. Szwed, Zabrze: A. Musialik-Lydka, Zabrze: A. Leopold-Jadczyk, E. Jedrzejczyk-Patej, M. Koziel, R. Lenarczyk, M. Mazurek, Z. Kalarus, Zabrze: K. Krzemien-Wolska, P. Starosta, E. Nowalany-Kozielska, Zakopane: A. Orzechowska, M. Szpot, M. Staszel, PORTUGAL Almada: S. Almeida, H. Pereira, L. Brandão Alves, R. Miranda, L. Ribeiro, Carnaxide Lisboa: F. Costa, F. Morgado, P. Carmo, P. Galvao Santos, R. Bernardo, P. Adragão, Santarém: G. Ferreira da Silva, M. Peres, M. Alves, M. Leal, Vila Real: A. Cordeiro, P. Magalhães, P. Fontes, S. Leão, Viseu: A. Delgado, A. Costa, B. Marmelo, B. Rodrigues, D. Moreira, J. Santos, L. Santos, ROMANIA Arad: A. Terchet, D. Darabantiu, S. Mercea, V. Turcin Halka, A. Pop Moldovan, Brasov: A. Gabor, B. Doka, G. Catanescu, H. Rus, L. Oboroceanu, E. Bobescu, Bucharest: R. Popescu, A. Dan, A. Buzea, I. Daha, G. Dan, I. Neuhoff, Bucharest: M. Baluta, R. Ploesteanu, N. Dumitrache, M. Vintila, Bucharest: A. Daraban, C. Japie, E. Badila, H. Tewelde, M. Hostiuc, S. Frunza, E. Tintea, D. Bartos, Bucharest: A. Ciobanu, I. Popescu, N. Toma, C. Gherghinescu, D. Cretu, N. Patrascu, C. Stoicescu, C. Udroiu, G. Bicescu, V. Vintila, D. Vinereanu, M. Cinteza, R. Rimbas, Iași: M. Grecu, Oradea: A. Cozma, F. Boros, M. Ille, O. Tica, R. Tor, A. Corina, A. Jeewooth, B. Maria, C. Georgiana, C. Natalia, D. Alin, D. Dinu-Andrei, M. Livia, R. Daniela, R. Larisa, S. Umaar, T. Tamara, M. Ioachim Popescu, Târgu Mureș: D. Nistor, I. Sus, O. Coborosanu, Timișoara: N. Alina-Ramona, R. Dan, L. Petrescu, Timișoara: G. Ionescu, I. Popescu, C. Vacarescu, E. Goanta, M. Mangea, A. Ionac, C. Mornos, D. Cozma, S. Pescariu, RUSSIAN FEDERATION Arkhangelsk: E. Solodovnicova, I. Soldatova, J. Shutova, L. Tjuleneva, T. Zubova, V. Uskov, Arkhangelsk: D. Obukhov, G. Rusanova, Arkhangelsk: I. Soldatova, N. Isakova, S. Odinsova, T. Arhipova, Arkhangelsk: E. Kazakevich, E. Serdechnaya, O. Zavyalova, Saint-Petersburg: T. Novikova, Saint-Petersburg: I. Riabaia, S. Zhigalov, Saint-Petersburg: E. Drozdova, I. Luchkina, Y. Monogarova, Vladivostok: D. Hegya, L. Rodionova, L. Rodionova, V. Nevzorova, Vladivostok: I. Soldatova, O. Lusanova, SERBIA Belgrade: A. Arandjelovic, D. Toncev, L. Vukmirovic, M. Radisavljevic, M. Milanov, N. Sekularac, Belgrade: M. Zdravkovic, S. Hinic, S. Dimkovic, T. Acimovic, J. Saric, S. Radovanovic, Belgrade: A. Kocijancic, B. Obrenovic-Kircanski, D. Kalimanovska Ostric, D. Simic, I. Jovanovic, I. Petrovic, M. Polovina, M. Vukicevic, M. Tomasevic, N. Mujovic, N. Radivojevic, O. Petrovic, S. Aleksandric, V. Kovacevic, Z. Mijatovic, B. Ivanovic, M. Tesic, T. Potpara, A. Ristic, B. Vujisic-Tesic, M. Nedeljkovic, Belgrade: A. Karadzic, A. Uscumlic, M. Prodanovic, M. Zlatar, M. Asanin, Belgrade: B. Bisenic, V. Vasic, Z. Popovic, Belgrade: D. Djikic, M. Sipic, V. Peric, B. Dejanovic, N. Milosevic, Belgrade: S. Backovic, A. Stevanovic, A. Andric, B. Pencic, M. Pavlovic-Kleut, V. Celic, Kragujevac: M. Pavlovic, M. Petrovic, M. Vuleta, N. Petrovic, S. Simovic, Z. Savovic, S. Milanov, G. Davidovic, V. Iric-Cupic, Niš: D. Djordjevic, M. Damjanovic, S. Zdravkovic, V. Topic, D. Stanojevic, M. Randjelovic, R. Jankovic-Tomasevic, V. Atanaskovic, S. Antic, M. Pavlovic, Niška Banja: D. Simonovic, M. Stojanovic, S. Stojanovic, V. Mitic, V. Ilic, D. Petrovic, M. Deljanin Ilic, S. Ilic, V. Stoickov, Pirot: S. Markovic, Šabac: A. Mijatovic, D. Tanasic, D. Petrovic, G. Radakovic, J. Peranovic, M. Pavlovic, N. Panic-Jelic, O. Vujadinovic, P. Pajic, S. Bekic, S. Kovacevic, SPAIN Alicante: A. García Fernandez, Benalmadena: A. Perez Cabeza, Córdoba: M. Anguita, Granada: L. Tercedor Sanchez, Huarte: E. Mau, J. Loayssa, M. Ayarra, M. Carpintero, Madrid: I. Roldán Rabadan, Murcia: M. Leal, Murcia: M. Gil Ortega, Murcia: A. Tello Montoliu, E. Orenes Piñero, S. Manzano Fernández, F. Marín, A. Romero Aniorte, A. Veliz Martínez, M. Quintana Giner, Pamplona: G. Ballesteros, M. Palacio, O. Alcalde, I. García-Bolao, San Juan de Alicante: V. Bertomeu Gonzalez, Santiago de Compostela: F. Otero-Raviña, J. García Seara, J. Gonzalez Juanatey, SWITZERLAND Geneva: N. Dayal, P. Maziarski, P. Gentil-Baron, D. Shah, TURKEY Adana: M. Koç, Afyon: E. Onrat, I. E. Dural, Ankara: K. Yilmaz, B. Özin, Ankara: S. Tan Kurklu, Y. Atmaca, Ankara: U. Canpolat, L. Tokgozoglu, Ankara: A. K. Dolu, B. Demirtas, D. Sahin, Ankara: O. Ozcan Celebi, E. Diker, Antalya: G. Gagirci, Bayraklı/Izmir: U.O.Turk, Bursa: H. Ari, Diyarbakır: N. Polat, N. Toprak, Gaziantep: M. Sucu, Görükle-Bursa: O. Akin Serdar, Istanbul: A. Taha Alper, Istanbul: A. Kepez, Istanbul: Y. Yuksel, Kurupelit - Samsun: A. Uzunselvi, S. Yuksel, M. Sahin, Merkez/Düzce: O. Kayapinar, Mersin: T. Ozcan, Sivas: H. Kaya, M. B. Yilmaz, Trabzon: M. Kutlu, Yüreğir-Adana: M. Demir, UNITED KINGDOM Barnstaple: C. Gibbs, S. Kaminskiene, M. Bryce, A. Skinner, G. Belcher, J. Hunt, L. Stancombe, B. Holbrook, C. Peters, S. Tettersell, Birmingham: A. Shantsila, D. Lane, K. Senoo, M. Proietti, K. Russell, P. Domingos, S. Hussain, J. Partridge, R. Haynes, S. Bahadur, R. Brown, S. McMahon, G. Y H Lip, Blackburn: J. McDonald, K. Balachandran, R. Singh, S. Garg, H. Desai, K. Davies, W. Goddard, Blackpool: G. Galasko, I. Rahman, Y. Chua, O. Payne, S. Preston, O. Brennan, L. Pedley, C. Whiteside, C. Dickinson, J. Brown, K. Jones, L. Benham, R. Brady, Carlisle: L. Buchanan, A. Ashton, H. Crowther, H. Fairlamb, S. Thornthwaite, C. Relph, A. McSkeane, U. Poultney, N. Kelsall, P. Rice, T. Wilson, Chertsey: M. Wrigley, R. Kaba, T. Patel, E. Young, J. Law, Cramlington: C. Runnett, H. Thomas, H. McKie, J. Fuller, S. Pick, Exeter: A. Sharp, A. Hunt, K. Thorpe, C. Hardman, E. Cusack, L. Adams, M. Hough, S. Keenan, A. Bowring, J. Watts, Great Yarmouth: J. Zaman, K. Goffin, H. Nutt, Harrogate: Y. Beerachee, J. Featherstone, C. Mills, J. Pearson, L. Stephenson, Huddersfield: S. Grant, A. Wilson, C. Hawksworth, I. Alam, M. Robinson, S. Ryan, Macclesfield: R. Egdell, E. Gibson, M. Holland, D. Leonard, Maidstone: B. Mishra, S. Ahmad, H. Randall, J. Hill, L. Reid, M. George, S. McKinley, L. Brockway, W. Milligan, Manchester: J. Sobolewska, J. Muir, L. Tuckis, L. Winstanley, P. Jacob, S. Kaye, L. Morby, Nottingham: A. Jan, T. Sewell, Poole: C. Boos, B. Wadams, C. Cope, P. Jefferey, Portsmouth: N. Andrews, A. Getty, A. Suttling, C. Turner, K. Hudson, R. Austin, S. Howe, Redhill: R. Iqbal, N. Gandhi, K. Brophy, P. Mirza, E. Willard, S. Collins, N. Ndlovu, Rhyl: E. Subkovas, V. Karthikeyan, L. Waggett, A. Wood, A. Bolger, J. Stockport, L. Evans, E. Harman, J. Starling, L. Williams, V. Saul, Salisbury: M. Sinha, L. Bell, S. Tudgay, S. Kemp, J. Brown, L. Frost, Shrewsbury: T. Ingram, A. Loughlin, C. Adams, M. Adams, F. Hurford, C. Owen, C. Miller, D. Donaldson, H. Tivenan, H. Button, South Shields: A. Nasser, O. Jhagra, B. Stidolph, C. Brown, C. Livingstone, M. Duffy, P. Madgwick, Southampton: P. Roberts, E. Greenwood, L. Fletcher, M. Beveridge, S. Earles, Taunton: D. McKenzie, D. Beacock, M. Dayer, M. Seddon, D. Greenwell, F. Luxton, F. Venn, H. Mills, J. Rewbury, K. James, K. Roberts, L. Tonks, Torquay: D. Felmeden, W. Taggu, A. Summerhayes, D. Hughes, J. Sutton, L. Felmeden, Watford: M. Khan, E. Walker, L. Norris, L. O'Donohoe, Weston-super-Mare: A. Mozid, H. Dymond, H. Lloyd-Jones, G. Saunders, D. Simmons, D. Coles, D. Cotterill, S. Beech, S. Kidd, Wolverhampton: B. Wrigley, S. Petkar, A. Smallwood, R. Jones, E. Radford, S. Milgate, S. Metherell, V. Cottam, Yeovil: C. Buckley, A. Broadley, D. Wood, J. Allison, K. Rennie, L. Balian, L. Howard, L. Pippard, S. Board, T. Pitt-Kerby.