Is Appropriate Management of Atrial Fibrillation in Primary Care a Utopia?

Setting

The study was conducted at a rural-type health center in Northern Greece (catchment area of about 22 000 inhabitants), operating 24 hours a day. During daylight, patients are normally assigned to their own general practitioners (GPs) and emergencies are managed by them. Late afternoon and night shifts are covered in a circular way (every GP has a certain number of night shifts monthly) and GPs share patient data. Seven trainees or GP specialists participated in the present study.

AF Classification

Arrhythmias were divided into “first detected” and “recurrent,” in accordance with recent guideline recommendations.^6,7 Recurrent cases were further classified as follows:

Recruitment

A total of 212 patients with arrhythmia symptoms (dyspnoea, palpitations, dizziness, chest discomfort, etc) or asymptomatic symptoms with a history of arrhythmia were examined and electrocardiograms (EKGs) were conducted to distinguish AF cases.^6,7 Both first detected and recurrent cases were included in the study. Special consideration was given to atrial flutter (AFL), as it can precede or coexist with AF. Uncertain cases were included in the sample and diagnosis was later confirmed by a referral to a cardiologist.

The exclusion criteria were as follows:

Measures and Procedures

A questionnaire was used with queries about demographics, lifestyle, arrhythmia-related diseases (hypertension, thyrotoxicosis, ischemic heart disease, acute fever), and chronic medication (rhythm and rate control drugs, antithrombotic agents, etc). Heavy caffeine intake was considered as the consumption of >4 cups per day, ⁸ while at-risk drinking was determined as >4 alcohol units per day or >14 per week for men and >3 units per day or >7 per week for women. ⁹

Blood pressure and temperature were measured, and a physical exam, auscultation, and a 12-lead EKG were performed. Patients’ previous EKGs were used to distinguish recurrent arrhythmias from newly detected ones. It should be mentioned that hard copies of EKGs are distributed compulsory to all patients of the health center and are attached to their personal health booklet. Lab analyses (CBC, thyroid, biochemical control) were carried out when necessary.

Treatment strategy for recurrent AF/AFL patients was based on the CHADS₂ index. One point each was assigned for congestive heart failure, hypertension, age ≥ 75, and diabetes mellitus, while 2 points were counted for prior stroke or transient ischemic attack. ¹⁰ According to the index, zero-score patients should initiate acetylsalicylic acid (ASA). For a score of 1, ASA or oral vitamin K antagonists (OVKAs) are recommended, and for scores of 2 or more, OVKAs are essential (with international normalized ratio [INR] range between 2 and 3). Target INR range was modified to 1.6 to 2.5 for patients over 74 years because of an increased risk of both thromboembolic and hemorrhagic stroke.^6,11

Finally, the brief and widely used Greek version of the General Health Questionnaire-12 (GHQ-12) was used to evaluate personal mental health perception. ¹²

Referrals to cardiologists were requested in cases of uncertain diagnosis, first detected AF/AFL, or CHADS₂ score > 3.

Statistical Analysis

Data were saved in an ad hoc MySQL database using the Lumos! platform for medical data collection. Statistical analysis was performed with SPSS version 15. Checks for missing data and out-of-range values, the Kolmogorov-Smirnov test for normality, and Levene’s for homogeneity were carried-out. Frequencies and descriptive statistics were computed. Differences between 2 groups were calculated with the Mann-Whitney test and among 3 or more groups with the Kruskal-Wallis test, followed by post hoc tests for multiple comparisons, in which the Bonferroni correction was applied. Spearman’s correlation was used to determine which variables were associated, and chi-square statistics were conducted for categorical data. Reported P values are 2-tailed; a P value ≥ .05 was considered statistically nonsignificant (with the exception of multiple post hoc tests, the effects of which are reported at an adjusted level of significance).

Main Findings

Our study focused on evaluating AF treatment and mental distress of patients. A total of 42 new arrhythmias were detected. Weak therapeutic practice was noticed. In 41 patients, medication was modified according to CHADS₂ index. Arrhythmia-related risk factors and mental distress were queried. Patients with paroxysmal and persistent AF/AFL had a significantly worse GHQ-12 score perhaps due to palpitations. ¹³

Strengths and Limitations

Insufficient data regarding management of arrhythmias in PHC settings of Greece encouraged the realization of this study. Cases of incorrect therapeutic approach and poor primary care control were identified. Thanks to this screening, 23 patients with noncardiac causes of arrhythmia were examined and treated by ensuring the abolition of the initial cause.

AF-related ischemic strokes carry twice the risk of death compared with strokes from other causes, and although oral anticoagulation can contribute to risk reduction, there is still significant under-treatment.^14,15 In the Euro Heart Survey only 61% of the high-risk patients were treated in accordance with the guidelines, while 28% were undertreated. ¹⁶

Decisions concerning the need for antithrombotic therapy should be taken after appropriate stroke and bleeding risk stratification.^6,7 CHADS₂ risk assessment revealed cases of mismanagement, as 18 patients with a score of 2 or more did not receive any anticoagulant treatment, and 24 patients used both OVKAs and ASA, though the coadministration provides no additional benefit for thromboprophylaxis. ⁶ A total of 22 of the 43 patients receiving OVKAs had an out-of-range INR. Similar rates have been seen in other studies. ¹⁶

The limitations of our study were as follows:

Primary Health Care Significance

A 2-fold drawback exists in Greece. First, the NHS has difficulties in financing all examinations and therapies because of high costs and a lack of human and material resources, particularly in rural areas. Second, patients often struggle to access PHC settings and cardiologists, due to economic reasons, insufficient family support, distance, etc.

In this context, a Holter monitor was used in 11 patients out of the 99 referrals and cardioversion was performed in 39 patients by cardiologists. In our PHC unit, the lack of a continuous EKG monitoring device prevented us from attempting pharmacological rhythm conversion.

The majority of recurrent AF/AFL patients used both rhythm and rate control drugs, often unnecessarily. Approximately three fourths received amiodarone, propafenone, or disopyramide, which are not considered to be the optimal treatment. According to the AFFIRM study, ²⁰ these drugs are not effective enough and have many side effects, which may lead to an impaired quality of life and suggest rate control as a preferred therapeutic approach. This reveals an insufficient knowledge of the GPs regarding international literature, clinical trials, and guidelines.

In current clinical practice, chronic prophylaxis with drugs is usually used in case of frequent paroxysms after the removal of precipitating factors such as caffeine. ⁷ However, many of our paroxysmal AF/AFL patients continued heavy caffeine consumption. Hughes et al, ²¹ seeking a consensus on the harmful effects of caffeine, stated that three fourths of the 697 medical specialists recommended caffeine reduction in patients with anxiety, arrhythmias, esophagitis/hiatal hernia, fibrocystic disease, insomnia, palpitations, and tachycardia. Finally, no differences were found in current smokers among the subtypes of AF/AFL, which suggests the need for implementing smoking cessation programs.

A correlation between GHQ-12 scores and certain arrhythmia subtypes was also noticed, and certain gender differences were revealed. Females seemed to report worse distress, which may be in accordance with other studies suggesting a greater impact of AF on the quality of life of women. ²¹

In conclusion, common practice in our health center did not fall within the acceptable range, as therapeutic strategies were often inappropriate. The current situation could be improved if GPs endeavored to enhance their knowledge of cardiology and manage arrhythmias better.