Reed Miller

November 12, 2012

LOS ANGELES — The care of atrial-fibrillation patients in the Persian Gulf region frequently deviates from the professional recommendations, and these deficiencies are leading to many poor patient outcomes, one-year results of the Gulf SAFE registry suggest.

The study found that, in the Gulf region, achieved levels of anticoagulation are suboptimal, cardioversion rates are low, hospitalization rates are high, and, despite a relatively young AF population, the outcomes are "not favorable," according to Dr Mohammad Zubaid (Mubarak Alkabeer Hospital, Kuwait), who presented the findings from the nonvalvular-AF patients in Gulf SAFE at the American Heart Association (AHA) 2012 Scientific Sessions last week.

As reported by heartwire , Gulf SAFE is a registry with 2043 consecutive patients presenting to an emergency room with AF (1721 nonvalvular AF, 322 valvular AF) between October 2009 and June 2010 at 23 hospitals in Yemen, Oman, the United Arab Emirates, Qatar, Bahrain, and Kuwait.

Gulf SAFE is the only multinational, Middle Eastern, observational AF registry. "Our aim was to study AF where the regular AF patient presents --the general hospital–-and stay away from the [electrophysiology] EP centers," Zubaid said. Fourteen of the hospitals submitting data to Gulf SAFE are secondary hospitals, and only five are university hospitals. An electrophysiologist was available in only about one-fifth of the hospitals.

The assigned respondent on the Gulf SAFE presentation, Dr Bernard Gersh (Mayo Clinic, Rochester, MN), commended the investigators for organizing the study. "It is not an easy thing to organize, and there is a real lack of data about atrial fibrillation in different regions in the world."

Relatively Young Patients With Many Risk Factors

The average age of the patients with nonvalvular AF in the study was about 59, and only 40% were 65 or older. The AF episode that drove the patient to come to the emergency department was the patient's first episode in 40% of cases. Despite their relatively young age, this cohort of patients had a relatively large burden of cardiometabolic risk factors, including hypertension, diabetes, and obesity, as well as evidence of significant cerebrovascular disease, including a high incidence of previously known coronary disease, left ventricular systolic dysfunction, and stroke and/or transient ischemic attacks (TIAs).

The mean CHADS2 score of these patients was 1.6, and about half of them had a CHADS2 score of >2. About 50% of the patients with CHADS2 score of 0 or 1 were discharged on warfarin, even though at the time of this study the CHADS2 guidelines did not recommend anticoagulation for these patients. Meanwhile, only 60% of the patients with a CHADS2 of >2 were prescribed warfarin, and less than 50% of the patients given warfarin were given the right dose, Zubaid said.

Our doctors shied away from using electricity.


About 72% of the patients were managed in the emergency department with a rate-control strategy. Of the 259 patients treated with cardioversion, only 34 were treated with electrical cardioversion while the majority received pharmacologic cardioversion. "Our doctors shied away from using electricity," Zubaid said.

Hospitalization rates were high in every subgroup, Zubaid said, and "this was disappointing for us." For example, even in the lone AF patients in the study, who had a mean age of 42 and no other cardiorespiratory symptoms, the hospitalization rate was 80%. "That's a very high hospital-admission rate for whatever reason."

The rate of all-cause death was 15% (263 patients). The stroke/TIA rate was 4% (73 patients), and 1.2% (20 patients) suffered a major bleed, which is relatively low for an AF population, "maybe because of age or because warfarin was not actually used properly," Zubaid said.

Death and stroke/TIA rates were lowest in patients who presented to the emergency department primarily because of their AF symptoms, while the highest mortality and stoke rates were in patients who presented to emergency department for other reasons, such as symptoms of a stroke.

Smokers, patients who came to the emergency department primarily for reasons other than AF symptoms, and patients with a CHADS2 score >2 or a CHA2DS2-VASc score >2 had a greater risk of stroke or TIA during the one-year follow-up. The risk of developing a stroke or TIA were nearly 60% lower for patients who were discharged home on warfarin compared with the patients without a warfarin prescription.

AF at a Young Age: "Extraordinarily Interesting"

Gersh pointed out that, compared with the patients in the ongoing ORBIT-AF registry of "real-world" AF patients in the US, the Gulf SAFE population was much younger, with more hypertension and more smokers but a lower average CHADS2 score.

A number of other studies have shown that usually "this is a disease, as we well know, of people in their 70s and 80s," Gersh said. So the relatively young age of the AF patients in Gulf SAFE is "extraordinarily interesting." One explanation would be that these are mostly patients with lone atrial fibrillation, which often strikes younger, "but their natural history doesn't suggest that and the prevalence of risk factors doesn't suggest that," Gersh said.

"The other explanation is that this is an expression of premature cardiovascular disease, and there is a high incidence of that in the Gulf," he said. "Many of us feel that atrial fibrillation is often the consequence of vascular disease causing diastolic dysfunction, increased arterial stiffness, left atrial volume overload, and then atrial fibrillation, as opposed to the genetic substrate that probably underlies most people with lone atrial fibrillation.

"I suspect that this very high early mortality and event rates [in Gulf SAFE] is due to comorbidities," he said.

Zubaid has no conflicts of interest. Gersh has consulted for Medtronic, Bristol-Myers Squibb, and Ortho-McNeil-Janssen Pharmaceuticals.