Knowledge – EHRA-PATHS

General

Atrial fibrillation: Incidence, prevalence, and predisposing conditions

Ball J, Carrington MJ, McMurray JJV, Stewart S. Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century. Int J Cardiol. 2013 Sep 1;167(5):1807–24.
Key findings from 182 studies were used to describe the indicative scope and impact of AF from an individual to population perspective. AF represents an evolving, global epidemic providing considerable challenges to minimise its impact from an individual to whole society perspective.
Di Carlo A, Bellino L, Consoli D, Mori F, Zaninelli A, Baldereschi M, et al. Prevalence of atrial fibrillation in the Italian elderly population and projections from 2020 to 2060 for Italy and the European Union: the FAI Project. Europace. 2019 Oct 1;21(10):1468–75.
In this study, the prevalence of atrial fibrillation (AF) is estimated in a representative sample of the Italian elderly population, projecting figures for Italy and the European Union. The findings indicate a high burden of AF in coming decades, especially among the oldest, who carry the highest AF-related risk of stroke and medical complications.
Friberg L, Bergfeldt L. Atrial fibrillation prevalence revisited. J Intern Med. 2013 Nov;274(5):461–8.
The prevalence of atrial fibrillation is at least 2.9% of the Swedish adult population, not counting ‘silent atrial fibrillation’. The official US figures probably underestimate the magnitude of the problem by a factor of 3-5.
Kannel WB, Wolf PA, Benjamin EJ, Levy D. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. 1998 Oct 16;82(8A):2N-9N.
Atrial fibrillation (AF) is the most common of cardiac rhythm disturbances and is responsible for substantial morbidity and mortality in the general population. The prevalence, incidence, prognosis and predisposing conditions for AF are described in this paper.
Krijthe BP, Kunst A, Benjamin EJ, Lip GYH, Franco OH, Hofman A, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013 Sep; 34(35):2746–51.
It is estimated that from 2010 to 2060, the number of adults 55 years and over with AF in the European Union will more than double. As AF is associated with significant morbidity and mortality, this increasing number of individuals with AF may have major public health implications.
Wilke T, Groth A, Mueller S, Pfannkuche M, Verheyen F, Linder R, et al. Incidence and prevalence of atrial fibrillation: an analysis based on 8.3 million patients. Europace. 2013 Apr;15(4):486–93.
A comparison of the distribution of AF prevalence/incidence in a German setting with that in already published studies showed that the German figures were higher, especially in the age groups above 70 years. This data shows that in a large industrial nation such as Germany, care provision structures are going to be challenged by a requirement to treat more AF patients in the future.
Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol. 2014;6:213–20.
In the last 20 years, atrial fibrillation (AF) has become one of the most important public health problems and a significant cause of increasing health care costs in western countries. This paper provides an updated picture of the epidemiological, clinical, and social impact of AF.
Who Is at Higher Risk for Atrial Fibrillation? [Internet]. Atrial Fibrillation Matters. [cited 2020 Mar 19].
Although it is not fully understood how atrial fibrillation develops, there are many factors that increase the risk of developing atrial fibrillation during life, examples of which are given in this article.

WP1

Multimorbidity, polypharmacy and sex-related aspects in AF patients
Related to WP1: Characterisation of comorbidities in elderly AF patients

Bähler C, Huber CA, Brüngger B, Reich O. Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study. BMC Health Serv Res [Internet]. 2015 Jan 22 [cited 2020 Mar 26];15.
Multimorbidity is associated with substantial higher health care utilization and costs in Switzerland. Quantitative data on the current burden of multimorbidity are fundamental for the management of patients in health service delivery systems and for health care policy debates about resource allocation. Strategies for a better coordination of multimorbid patients are urgently needed.
Haider SI, Johnell K, Thorslund M, Fastbom J. Trends in polypharmacy and potential drug-drug interactions across educational groups in elderly patients in Sweden for the period 1992 – 2002. Int J Clin Pharmacol Ther. 2007 Dec;45(12):643–53.
This study indicates that the use of drugs, polypharmacy and potential drug-drug interactions (DDIs) have increased from 1992 to 2002 among the elderly. Polypharmacy and potential DDIs represent potential health hazards for the elderly. Therefore, the trends of increasing polypharmacy and drug-drug interactions deserve attention and the mechanisms behind should be investigated further.
Jani BD, Nicholl BI, McQueenie R, Connelly DT, Hanlon P, Gallacher KI, et al. Multimorbidity and co-morbidity in atrial fibrillation and effects on survival: findings from UK Biobank cohort. Europace. 2018 01;20(FI_3):f329–36.
Survival in middle-aged to older individuals with self-reported AF is strongly correlated with the level of multimorbidity. This group should be targeted for interventions to optimize their management, which in turn may potentially reduce the impact of their co-morbidities on survival. Future AF clinical guidelines need to place greater emphasis on the issue of co-morbidity.
Jørgensen HS, Nakayama H, Reith J, Raaschou HO, Olsen TS. Acute stroke with atrial fibrillation. The Copenhagen Stroke Study. Stroke. 1996 Oct;27(10):1765–9.
The study is part of the Copenhagen Stroke Study, a prospective, community-based study of 1197 patients with acute stroke treated on a stroke unit from the time of acute admission to the end of rehabilitation. Stroke in patients with AF is generally more severe and outcome markedly poorer than in patients with sinus rhythm. This accentuates the importance of anticoagulant treatment of individuals with AF.
Maher RL, Hanlon JT, Hajjar ER. Clinical Consequences of Polypharmacy in Elderly. Expert Opin Drug Saf [Internet]. 2014 Jan [cited 2020 Mar 19];13(1).
Polypharmacy, defined as the use of multiple drugs or more than are medically necessary, is a growing concern for older adults. This paper presents information about; 1.) Prevalence of polypharmacy and unnecessary medication use ; 2.) Negative Consequences of Polypharmacy; 3.) Interventions to improve polypharmacy.
Shaikh F, Pasch LB, Newton PJ, Bajorek BV, Ferguson C. Addressing Multimorbidity and Polypharmacy in Individuals With Atrial Fibrillation. Curr Cardiol Rep. 2018 24;20(5):32.
Due to the structural and/or electrophysiological abnormalities that occur in AF, patients are managed through the use of prophylactic anticoagulant and rate and/or rhythm control medications. However, these medications are considered high risk and can increase the chances of medication misadventure. Additionally, AF rarely occurs in isolation and is known to coexist with multiple other medical comorbidities, i.e. multimorbidity. This also increases the number of medications, i.e. polypharmacy and pill burden, which results in treatment non-compliance to the prescribed therapy.
Valderas JM, Starfield B, Sibbald B, Salisbury C, Roland M. Defining Comorbidity: Implications for Understanding Health and Health Services. Ann Fam Med. 2009 Jul;7(4):357–63.
In this article, definitions of comorbidity and their relationship to related constructs, such as multimorbidity, morbidity burden, and patient complexity, are reviewed.
Volgman AS, Manankil MF, Mookherjee D, Trohman RG. Women with atrial fibrillation: Greater risk, less attention. Gend Med. 2009 Sep 1;6(3):419–32.
Women have a significantly higher risk of AF-related stroke than do men and are more likely to live with stroke-related disability and a significantly lower quality of life. This article provides an overview of the contributing factors and clinical presentation of AF in women and offers a rational, safe, effective, and gender-specific approach to therapy for women with AF.

WP2

Management of multimorbid elderly AF patients
Related to WP2: Mapping clinical practices and gap identification

Johnsen SP, Dalby LW, Täckström T, Olsen J, Fraschke A. Cost of illness of atrial fibrillation: a nationwide study of societal impact. BMC Health Serv Res. 2017 Nov 10;17(1):714.
This incidence-based cost-of-illness study based on national registries covering the entire population of Denmark, shows that societal costs attributable to atrial fibrillation are significant. Reducing the need for hospitalizations, in particular from stroke, is a key factor in controlling the costs.
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016 Oct 7;37(38):2893–962.
This article presents the 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with European Association for Cardio-Thoraric Surgery (EACTS).
Naccarelli GV, Johnston SS, Lin J, Patel PP, Schulman KL. Cost burden of cardiovascular hospitalization and mortality in ATHENA-like patients with atrial fibrillation/atrial flutter in the United States. Clin Cardiol. 2010 May;33(5):270–9.
The ATHENA trial demonstrated that dronedarone reduced the risk of cardiovascular (CV) hospitalization/death by 24% in patients with atrial fibrillation (AF) and atrial flutter (AFL). This follow-up study showed that health care costs associated with CV hospitalizations and inpatient deaths among ATHENA-like patients in the US are high. Novel antiarrhythmic therapies (such as dronedarone), with the potential to reduce CV hospitalizations/mortality in similar patients, could decrease health care costs if adopted in clinical practice.
Ringborg A, Nieuwlaat R, Lindgren P, Jönsson B, Fidan D, Maggioni AP, et al. Costs of atrial fibrillation in five European countries: results from the Euro Heart Survey on atrial fibrillation. Europace. 2008 Apr;10(4):403–11.
In this study the estimated costs are presented, both hospitalisation costs and costs incurred on an annual basis by patients with atrial fibrillation (AF) in Greece, Italy, Poland, Spain, and the Netherlands.
Stewart S, Murphy N, Walker A, McGuire A, McMurray JJV. Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart. 2004 Mar;90(3):286–92.
This paper provides an evaluation of the cost of atrial fibrillation (AF) to health and social services in the UK in 1995 and a projection of this estimate , based on epidemiological trends.
Wolowacz SE, Samuel M, Brennan VK, Jasso-Mosqueda J-G, Van Gelder IC. The cost of illness of atrial fibrillation: a systematic review of the recent literature. Europace. 2011 Oct;13(10):1375–85.
This is the first systematic review of the economic burden of AF, describing the cost of illness associated with AF, including those associated with stroke and bleeding complications; the main cost drivers; and the resources directly involved in providing health care (direct costs) and other costs associated with AF, such as lost work productivity (indirect costs).

WP3

Integrated management of AF
Related to WP3: Design and development of new care pathways

Hendriks JML, Tieleman RG, Vrijhoef HJM, Wijtvliet P, Gallagher C, Prins MH, et al. Integrated specialized atrial fibrillation clinics reduce all-cause mortality: post hoc analysis of a randomized clinical trial. Europace. 2019 Aug 7;
An integrated specialized AF-Clinic reduces all-cause mortality compared with usual care. These findings provide compelling evidence that an integrated approach should be widely implemented in AF management.
Guthrie B, Payne K, Alderson P, McMurdo MET, Mercer SW. Adapting clinical guidelines to take account of multimorbidity. BMJ. 2012 Oct 4;345:e6341
Care of patients with multimorbidity could be improved if new technology is used to translate guidelines into individual management and tailor advice to each patient’s circumstances.
Stewart S. Bringing order to chaos: the case for integrated management of atrial fibrillation. Heart. 2017 Dec 1;103(24):1928–9.
Initial outcomes from integrated management programmes for AF are promising. However, there is still much to be investigated; particularly in respect to cost-effectively dealing what is likely to be an increasingly older and more clinically complex patient population in whom the margin of error (in terms of benefits vs risk) is likely to become narrower.

WP4

Interdisciplinary, patient-centred, systematic care pathways
Related to WP4: Implementation of new care pathways

COMMUNICATION FROM THE COMMISSION On effective, accessible and resilient health systems [Internet]. [cited 2020 Mar 13].
To ensure that citizens’ aspirations to high quality care can be met, this communication from the European Commission highlights a number of initiatives through which the EU can support policy makers in the Member States. The focus will have to be on methods and tools that will allow Member States to achieve greater effectiveness, accessibility and resilience of their health systems, in line with reform recommendations addressed to Member States in the context of the European Semester.
WHO_HIS_HSR_16.1_eng.pdf [Internet]. [cited 2020 Mar 13].
The strategic plan, launched by the Alliance for Health Policy and Systems Research, outlines a challenging and exciting agenda to provide a unique forum for decision-makers in health policy and systems research, support institutional capacity for training and mentorship, stimulate knowledge generation and innovation, and encourage the demand for and use of research.

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