_02_FC_PO_Gorczyca

PRACA ORYGINALNA

Baseline characteristics of patients with non-valvular atrial fibrillation — single-centre registry

Charakterystyka hospitalizowanych chorych z niezastawkowym migotaniem przedsionków — rejestr jednoośrodkowy

Iwona Gorczyca-Michta1, Beata Wożakowska-Kapłon1, 2

1I st Cardiac Clinical Unit, Swietokrzyskie Cardiac Centre, Kielce, Poland

2The Faculty of Medicine and Health Science, Jan Kochanowski University in Kielce, Poland

Address for correspondence: dr n. med. Iwona Gorczyca-Michta, I Klinika Kardiologii i Elektroterapii, Świętokrzyskie Centrum Kardiologii, ul. Grunwaldzka 45, 25–736 Kielce, e-mail: iwona.gorczyca@interia.pl

Abstract

Introduction. The evaluation of clinical profile of patients with atrial fibrillation (AF) is very important because it determines the choice of antithrombotic and anti-arrhythmic therapy. The presence of concomitant diseases, as well as the age and sex of patients with AF, influence the risk of stroke.

The aim of the study was to analyse demographic data and assess the prevalence of concomitant diseases and the risk of thromboembolic and bleeding complications in hospitalized patients with AF.

Material and methods. Our study is a single-centre, retrospective registry. The analysis included data of 4,099 patients hospitalized in reference cardiology centre who were discharged with the diagnosis of AF in the years 2004–2012.

Results. The analysed group included 4,099 patients with AF; 2,244 study participants (54.7%) were females. Mean age of whole study population was 70.6 years. Chronic AF was diagnosed in 1,875 patients (45.7%). Paroxysmal AF occurred in 1,767 patients (43.1%). The most frequent diseases that coexisted with AF in the study group were: hypertension in 3,067 patients (74.8%), ischaemic heart disease in 2,324 patients (56.7%), and heart failure in 2,247 patients (54.8%). Among study participants, 297 patients (7.2%) were free from risk factors of stroke (CHADS2 = 0); 1,042 patients (25.4%) had CHADS2 score of 1 and 2,760 patients (67.4%) had CHADS2 score of 2 or more points.

Conclusions. In our registry of hospitalized patients with AF, the most prevalent group were elderly patients with many concomitant diseases that can be considered as a cause of arrhythmia, but also influence thromboembolic risk in these patients and determine the need for antithrombotic therapy.

Key words: atrial fibrillation, risk of stroke, registry

Folia Cardiologica 2016; 11, 2: 98–103

Introduction

Atrial fibrillation (AF) is the most frequent chronic arrhythmia, affecting 11.5% of global population [1]. In the United States, about 2.3 million people suffer from AF, while the number of patient with AF in Poland is about 400,000 [2, 3]. It is estimated that, due to population ageing, resulting in more frequent occurrence of the diseases promoting AF development, the number of patients with arrhythmias will at least double by the year 2050 [4]. The increase in AF prevalence in recent years has been confirmed by the data from Spanish registry, showing 27% increase in AF prevalence during 10 years: from 4.8% in 1999 to 6.14% in 2009 [5]. The prevalence of AF increases with age; it is 0.1% in subjects younger than 50 years, whereas in patients above 85 years it rises to 17.8% [6]. The evaluation of clinical profile of patients with AF is very important because it determines the choice of antithrombotic and anti-arrhythmic therapy. The presence of concomitant diseases, as well as the age and sex of patients with AF, influence the risk of stroke. Among those diagnosed with AF, there are very few patients without comorbidities that are risk factors for thromboembolic events. According to data from REALISE-AF registry of 10,523 patients with AF, only in 5% patients no concomitant diseases were present [7].

The aim of the study was to analyse demographic data and assess the prevalence of concomitant diseases and the risk of thromboembolic and bleeding complications in hospitalized patients with AF.

Material and methods

Our study is a multicentre, retrospective registry. The analysis included data of 4,099 patients discharged from reference cardiology centre who were hospitalized in the years 2004–2012. Consecutive patients hospitalized for AF were included in the study. Included in the analysis were medical records with complete data allowing for the assessment of thromboembolic and bleeding complication risks according to currently used scales, as well as the data on recommended antithrombotic prophylaxis. For patients who were hospitalized more than once, only data concerning the last hospitalization were analysed. Exclusion criteria were valvular AF and in-hospital death.

The study included patients hospitalized in the years 2004–2012 when mainly CHADS2 scale was used and therefore this scale was utilised for thromboembolic risk assessment. CHADS2 score of 0 points means low thromboembolic risk, 1 point — moderate risk, and 2 points or more — high risk of stroke. Also CHA2DS2VASc score was used in the study. The risk of stroke assessed with this scale corresponds to CHADS2 score.

When assessing the risk of bleeding complication according to HAS-BLED score, following conditions were considered as promoting bleeding episodes: anaemia, defined as haemoglobin level below 13 g/dL in women and below 12 g/dL in men, and thrombocytopoenia below 150 G/L. Labile international normalized ratio (INR) was defined as time in therapeutic range (TTR) below 60%. Impaired kidney function was defined as creatinine levels ≥ 220 µmol/L or chronic dialysotherapy or previous kidney transplantation. Impaired liver function was defined as chronic liver disease or biochemically significant liver injury (bilirubin level > than 2 × upper limit of normal [ULN] or aminotransferase activity higher than 3 × ULN).

The study was approved by regional Bioethics Committee (No 12/21011).

Results

The analysed group included 4,099 patients with AF; 2,244 study participants (54.7%) were females. Mean age of whole study population was 70.6 (± 10.9) years and it was 68.2 (± 11.5) years in men and 73.5(± 9.4) years in women. There were 1,535 women (68.4% of all women) and 1,440 men (77.6% of all men) older than 65 years. Overall 2,975 patients (72.6%) were above 65 years of age. There were 1,701 patients (41.5%) older than 75 years (Fig. 1).

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Figure 1. Age of patients with atrial fibrillation according to gender

Patients with AF were hospitalized mainly to perform elective procedures: cardiac stimulation system implantation/reimplantation — 1,422 patients (34.7%), coronary angiography or coronary angioplasty — 250 patients (6.1%) or electrophysiology study and/or ablation — 57 patients (1.4%). Aggravation of the underlying disease was the reason for hospitalization in 845 patients (20.6%) with AF. Most of them (580 patients; 68.4% of patients hospitalized for underlying disease) presented with decompensation of heart failure caused by other condition than AF with rapid ventricular rate. AF with rapid heart rate was a reason for hospitalization in 127 patients (15%), ischaemic heart disease aggravation — in 102 patients (12.1%), and hypertensive crisis — in 36 patients (4.5%). Angina pectoris was diagnosed in 142 patients, myocardial infarction without ST segment elevation — in 213 patients, and myocardial infarction with ST segment elevation — in 232 patients, that is in 24.2%, 36.3% and 39.5% patients with acute coronary syndrome, respectively.

The most common type of arrhythmia, observed in 1,875 patients (45.7%), was chronic AF. Paroxysmal AF occurred in 1,767 patients (43.1%). Thirty patients (0.7%) had first detected AF. Persistent arrhythmia was observed in 426 patients (10.4%).

The most frequent diseases that coexisted with AF in the study group were: hypertension in 3,067 patients (74.8%), ischaemic heart disease in 2,324 patients (56.7%), and heart failure in 2,247 patients (54.8%). Most patients with heart failure were in NYHA class II (1,130 patients, 50.3% of patients with heart failure) and III (944 patients, 42% of patients with heart failure). Special attention should be paid to high prevalence of diabetes observed in 893 patients (21.8%) and thyroid diseases — in 667 patients (16.2%) (Tab. 1).

Table 1. Clinical characteristics of study population with atrial fibrillation

Clinical features

Number of patients n = 4099

Percentage of patients (%)

Concomitant diseases

Hypertension

3067

74.8

Ischaemic heart disease

2324

56.7

Prior myocardial infarction

1116

27.2

Acute coronary syndrome

587

14.7

Prior coronary angioplasty

633

15.4

Prior arterial by-pass grafting

152

3.7

Heart failure

2247

54.8

Renal insufficiency (GFR < 60 ml/min)

2206

53.8

Dyslipidaemia

1897

46.3

Hypercholesterolaemia

1307

31.9

Hypertriglyceridaemia

213

5.2

Combined hyperlipidaemia

377

9.2

Type 2 diabetes

893

21.8

Thyroid diseases

667

16.2

Hyperthyroidism

304

7.4

Hypothyroidism

202

4.9

Nodular goitre with euthyreosis

161

3.9

Chronic obstructive pulmonary disease

337

8.2

Neoplastic disease

173

4.2

Gastric/duodenal ulcer

169

4.1

Lower extremity atherosclerosis

79

1.9

Thromboembolic complication

Prior stroke

434

10.6

Prior TIA

59

1.4

Prior peripheral embolism

80

2

Electrophysiological interventions

Pacemaker implantation

1721

42

Cardioverter-defibrillator implantation

141

3.4

CRT system implantation

15

0.04

CRT — cardiac resynchronization therapy; GFR — glomerular filtration rate; TIA — transient ischaemic attack

In the assessment of the risk of stroke, mean CHADS2 score in the study population was 2.2 points. Among study participants, 297 patients (7.2%) were free from risk factors for stroke (CHADS2 = 0). CHADS2 score values were as follows: 1,042 patients (25.4%) had CHADS2 score of 1 and 2,760 patients (67.4%) had CHADS2 score of 2 or more points. Figure 2 shows CHADS2 score in the study group.

64415.jpg

Figure 2. CHADS2 score in the study group

Mean CHA2DS2VASc score in the study group was 3.7. Based on CHA2DS2VASc score, 127 patients (3.1%) were considered as free from risk factors for stroke complications. Overall 364 patients (8.9%) had CHA2DS2VASc score of 1 point. Among them, there were 46 women (1.1 of study group) whose score was 1 due to female sex). There were 3,607 patients (88%) with the CHA2DS2VASc score of 2 or more points. Figure 3 presents CHA2DS2VASc score in the study group.

64406.jpg

Figure 3. CHA2DS2VASc score in the study group

Mean HAS-BLED score in the study group was 2.1. Based on HASBLED score, 1,418 patients (34%) were at high risk for bleeding and 2,681 patients (65.4%) were at low risk for bleeding.

The risks of bleeding complications were compared between the groups of patients with low, moderate and high thromboembolic risk. High bleeding risk (HAS-BLED ≥ 3 pts) was found in 5 patients (1.7%) with no risk factors for stroke, 143 patients (13.7%) with moderate risk of stroke and 1,256 patients (45.5%) with high risk of stroke (Fig. 4).

64395.jpg

Figure 4. Risk of bleeding complications in patients with low, moderate and high risk of stroke

Discussion

The mean age of the patients included in our study (n = 4,099) was 71 years. In this group, 42% of patients were older than 75 years, and every fifth patient was older than 80 years. Women were most prevalent in the study population (55%). The mean age of the patient in our study was similar to that of patients in the first cohort of European GARFIELD Registry — 70 years [8]. The proportion of GARFIELD Registry patients older than 75 years is 39%. Patients included in our study were younger than those included in the ATRIUM Registry (mean age 72 years) [9] and other patients hospitalized in District Hospital in Grodzisk Mazowiecki, Poland, (mean age 74 years) [10]. On the other hand, our patients were younger than patients included in Euro Heart Survey on Atrial Fibrillation Registry (mean age 68 years) [11], AFNET registry (mean age 68 years) [12] and REALISE-AF trial [7]. This may be caused by the fact that these registries included both inpatients and outpatients, while in our paper only hospitalized patients were analysed. Women were 55% of patients with AF hospitalized in Kielce Centre, whereas in cited registries women were in minority [9, 11, 12]. Only in the study of Bednarski et al., including 613 patients treated in district hospital, most of the patients were female (51%) [10], like in our study. Almost in all European countries there is a preponderance of women in general population. Higher percentage of women in two mentioned Polish studies may be probably attributed to older age of its participants compared with those included in GARFIELD, EHS, AFNET and REALISE-AF registries, and to the fact that AF prevalence is higher in elderly women than in elderly men, which is related to longer life-span of women.

The percentage of patients with persistent AF in the population of our study was as low as 10%. Bednarski et al. [10] obtained similar results; he reported persistent AF in 12% of studied patients. In a study including 1,559 patients hospitalized in Bialystok centre, persistent AF was found in 17% of patients [13]. Finally, persistent AF was found in 22% patients participating in the Euro Heart Survey on Atrial Fibrillation trial [11] and in 27% patients in ATRIUM registry [9]. There are also similar discrepancies in reported rate of first detected AF. In our study, this form of arrhythmia was found in only 0.7%, whereas in the AFNET registry of patients treated in hospital and outpatient condition, the percentage of patients with first detected AF was 11% [12]. Our study included only patients hospitalized in cardiology department, whereas in patients with first detected AF return to normal sinus rhythm due to pharmacological cardioversion is usually obtained at the emergency care unit. Moreover, those with first detected AF, particularly young patients without comorbidities, are also hospitalized in the departments of internal diseases or treated on an outpatient basis. In our study, almost half of the patients (46%) had persistent form of arrhythmia, which probably reflected advanced age of study participants and the presence of concomitant diseases. Similar percentage of patients with persistent AF was found in the ATRIUM (42%) [9] and REALISE-AF (46%) [7] trials. Contrary, in the Euro Heart Survey on Atrial Fibrillation trial, the proportion of patients with chronic AF was 29% [11].

In our study, 75% AF patients had underlying hypertension. Similarly, in the GARFIELD registry 78% subjects had a history of hypertension [8]. Higher proportion of AF patients with hypertension was noted in the ATRIUM registry (84%) [9], and lower — in the European registry (62%) [11] and the AFNET trial (69%) [12]. Worth noting is high percentage of patient with AF and heart failure (55%) compared with other registries. Higher than in our study proportion of patients with heart failure (62%) was shown in the study performed in a district hospital. In the GARFIELD registry heart failure was diagnosed in 21% of patient with AF. The patients included in the GARFIELD registry are at similar age as the patients in our study; however, the lower prevalence of heart failure in the GARFIELD registry population may result from the fact that it includes the patients with first diagnosed AF [8]. Lower proportion of patients with heart failure was also found in the Euro Heart Survey on Atrial Fibrillation trial, which may be attributed to younger age of the patients and considerably lower percentage of patients with chronic AF than in our study (29% vs 46%). High percentage of hospitalized patients with heart failure observed in the study performed in Świętokrzyskie Centre is associated with the profile of this centre. The most numerous group were the patients hospitalized in order to perform elective procedures, including implantation and reimplantation of cardioverters-defibrillators or cardiac resynchronisation systems. This is the only centre in the region where implantations of cardiac resynchronization therapy systems are performed. Furthermore, patients with heart failure were the most numerous group of patients hospitalized for exacerbation of underlying disease (68%).

In our study, the underlying ischaemic heart disease was found more frequently in patients with AF compared with other registries: 57% vs 19 % (GARFIELD), 28% (AFNET), 32% (Euro Heart Survey on Atrial Fibrillation) and 35% (ATRIUM). This might result from 24-hour access to haemodynamics laboratory and hospitalization of patients with acute coronary syndromes who were also referred from other centres in the region. In these patients ischaemic heart disease often led to heart failure.

Mean CHADS2 score in the population of our study was 2.2. Among study participants, 7% were free from risk factors for stroke, 26% had CHADS2 score of 1 point, and in 67% CHADS2 score was 2 or more. Similar mean CHADS2 score was obtained in the ATRIUM trial [9]. Bednarski et al. [10] found high thromboembolic risk in 85% of analysed population, and there were only 2% of patients with no risk factors for stroke. Similar results were reported by Łopatowska et al. [13] who analysed 1,559 patients with both valvular and non-valvular AF and found that only 3% of patients were free from risk factors for stroke. Conversely, in the Euro Heart Survey on Atrial Fibrillation there were as many as 18% of patients in whom no thromboembolic risk factors were found, and 49% of patients were considered as having high-risk for stroke [11]. In a group of Polish patients included in the GARFIELD registry, low risk of stroke was found in 4.4% patients in the first cohort and 5.5% patients in the second cohort, moderate risk — in 38.7% patients in the first cohort, 39.8% patients in the second cohort 2, and high risk in 56.9% and 54.7% of patients, respectively [14].

In our study, only small percent of patients had isolated AF, which was consistent with the results obtained by other authors. The vast majority of patients with arrhythmia had comorbid conditions that contributed to significant thromboembolic risk in these patients.

Conclusions

In our registry of hospitalized patients with AF, the most prevalent group were elderly patients with many concomitant diseases that can be considered as a cause of arrhythmia, but also influence thromboembolic risk in these patients and determine the need for antithrombotic therapy.

Conflict of interest(s)

None declared.

Streszczenie

Wstęp. Ocena profilu klinicznego chorych z migotaniem przedsionków (AF) jest niezwykle istotna, ponieważ zależy od niej postępowanie przeciwkrzepliwe i antyarytmiczne. Obecność schorzeń współistniejących, wiek i płeć u chorych z AF wpływają na ryzyko powikłań zakrzepowo-zatorowych.

Celem pracy jest analiza danych demograficznych, ocena częstości występowania schorzeń współistniejących oraz ryzyka zakrzepowo-zatorowego i ryzyka powikłań krwotocznych u hospitalizowanych chorych z AF.

Materiał i metody. Prezentowane badanie jest jednoośrodkowym, retrospektywnym rejestrem. Analizą objęto dane 4099 pacjentów wypisanych z kliniki kardiologii ośrodka referencyjnego w latach 2004–2012 z rozpoznaniem AF.

Wyniki. W analizowanej grupie obejmującej 4099 chorych z AF kobiety stanowiły 2244 badanych (54,7%). Średnia wieku pacjentów wynosiła 70,6 roku. Utrwalone AF występowało u 1875 chorych (45,7%), a napadowe AF stwierdzono u 1767 chorych (43,1%). W badanej grupie z AF najczęściej współistniały nadciśnienie tętnicze — u 3067 chorych (74,8%), choroba niedokrwienna serca — u 2324 chorych (56,7%) oraz niewydolność serca — u 2247 chorych (54,8%). W badanej grupie u 297 pacjentów (7,2%) nie stwierdzono czynników ryzyka powikłań zakrzepowo-zatorowych (CHADS2 = 0 pkt.). U 1042 pacjentów (25,4%) stwierdzono wynik w skali CHADS2 równy 1, a u 2760 pacjentów (67,4%) wynosił on 2 i więcej punktów.

Wnioski. W prezentowanym rejestrze hospitalizowanych chorych większość pacjentów z AF stanowiły osoby w podeszłym wieku z licznymi współistniejącymi schorzeniami, które jednocześnie można uznać za przyczynę wystąpienia arytmii i które wpływają na ryzyko zakrzepowo-zatorowe u tych chorych, decydując o konieczności stosowania leczenia przeciwkrzepliwego.

Słowa kluczowe: migotanie przedsionków, ryzyko zakrzepowo-zatorowe, rejestr

Folia Cardiologica 2016; 11, 2: 98–103

References

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Komentarz

W ostatnim czasie kilka badań populacyjnych oraz szeroko zakrojonych rejestrów dostarczyło interesujących danych na temat częstości występowania, chorobowości oraz rokowania u pacjentów z niezastawkowym migotaniem przedsionków (AF, atrial fibrillation) [1, 2]. Jakkolwiek trzeba dodać, że dane dotyczące polskich pacjentów są raczej ograniczone. Dlatego uważam, że Autorzy badania podjęli ważny temat, zwłaszcza wobec faktu, że AF jest najczęstszą utrwaloną arytmią, a liczba chorych zwiększy się co najmniej 2-krotnie do 2050 roku.

Omawiana praca dostarcza istotnych i szczegółowych informacji na temat chorób towarzyszących arytmii. Oczywiście analizowana populacja stanowi heterogenną grupę — począwszy od pacjentów w ciężkim stanie ogólnym, a skończywszy na chorych w stabilnym stanie przyjętych do szpitala w celu planowego wszczepienia stymulatora.

W większości rejestrów, podobnie jak w omawianej pracy, AF jest związane z co najmniej jednym czynnikiem ryzyka i jest to najczęściej nadciśnienie tętnicze [1, 2]. Według rejestru z Kliniki Kardiologii w Białymstoku 97% chorych było obciążonych co najmniej jednym czynnikiem ryzyka. Około połowa miała chorobę wieńcową i niewydolność serca. Co trzeci pacjent był otyły i chorował na cukrzycę lub niedokrwistość [3]. Podobnie w pracy dr Gorczycy-Michty i wsp. z AF najczęściej współistniały nadciśnienie tętnicze (u 74,8% chorych), choroba niedokrwienna serca (u 56,7%) oraz niewydolność serca (u 54,8%). Przytaczane odsetki są zgodne ze stwierdzonymi w Euro Heart Survey, gdzie u 90% pacjentów występowały choroby towarzyszące, z nadciśnieniem tętniczym jako najczęściej występującym [4].

Szczególnie często w omawianej pracy AF wiązało się z niewydolnością serca i jej zaostrzeniem [2, 4]. W rejestrze GARFIELD niewydolność serca występowała u 21% pacjentów z AF. Objęta nim populacja była w podobnym wieku, co pacjenci w prezentowanym badaniu, a znacznie niższy odsetek chorych z niewydolnością serca być może wynikał z faktu, że do rejestru GARFIELD są włączani chorzy z nowo rozpoznanym AF [5]. Co interesujące, w szwedzkim rejestrze wykazano, że choroby towarzyszące, które nie są uwzględnione w skali CHA2DS2-VASc, takie jak nowotwory, przewlekła choroba nerek czy przewlekła obturacyjna choroba płuc najbardziej, wpływały na śmiertelność [6].

Analiza typów AF jest ważnym zagadnieniem, ponieważ wiąże się z odmiennym postępowaniem terapeutycznym. Jest niewiele badań wskazujących na różnice w charakterystyce populacji i postępowaniu u chorych z poszczególnymi typami AF [2]. W omawianej populacji najczęstsze było utrwalone AF, podobnie jak w rejestrach AFNET i PREFER [2, 7], natomiast w greckim rejestrze RAFTING oraz w analizie białostockiej dominował typ napadowy [8]. Nieuwlaat i wsp. [4] wykazali, że pacjenci z utrwalonym AF byli starsi, częściej mieli objawy niewydolności serca i cukrzycę oraz przebyli udar niedokrwienny. Nie stwierdzono natomiast istotnych różnic w zakresie zapadalności na chorobę wieńcową, w tym częstości przebytego zawału oraz rewaskularyzacji. Przewlekła choroba nerek także występowała z podobną częstością. Zbieżne dane opublikowano także na podstawie rejestru AFNET [2]. Jednak w większości dużych rejestrów napadowy typ AF wyraźnie się wiązał z mniejszą liczbą chorób towarzyszących.

Różnice między kobietami i mężczyznami w zakresie epidemiologii są ewidentne i opisywano je już w kilku publikacjach [1, 9, 10]. Według rejestru EORP-AF kobiety z AF są starsze, częściej mają niewydolność serca pochodzenia pozawieńcowego oraz niewydolność z zachowaną funkcją skurczową lewej komory [1]. Podobnie w rejestrze Euro Heart Survey on Atrial Fibrillation występowało u nich więcej chorób towarzyszących oraz częściej diagnozowano niewydolność z zachowana funkcją skurczową [10]. Według EORP-AF i Euro Heart Survey nie odnotowano różnic pod względem typu AF między mężczyznami i kobietami [1, 10].

Pod względem ryzyka udaru ocenianego za pomocą CHA2DS2-VASc polska populacja chorych z AF jest podobna do europejskiej; punktacja w omawianej skali wynosi, odpowiednio, 3,7 i 3,4 punktu. Natomiast ryzyko krwawienia według skali HAS-BLED ocenia się na 2,1 punktu w Polsce i 2,0 punktu w Europie [7].

Analiza danych demograficznych, częstości występowania schorzeń współistniejących oraz ryzyka zakrzepowo-zatorowego i ryzyka powikłań krwotocznych u hospitalizowanych chorych z AF pozostaje sprawą bardzo aktualną. To właśnie w badaniach populacyjnych udowodniono, że AF jest niezależnym czynnikiem podwyższonego ryzyka zgonu. Dane z badania Framingham dowiodły 1,5–1,9-krotnego wzrostu śmiertelności u pacjentów z AF — zarówno u kobiet, jak i u mężczyzn — niezależnie od wieku, a także po uwzględnieniu chorób towarzyszących.

Tomasz-Kazberuk_Anna.jpg

dr hab. n. med. Anna Tomaszuk-Kazberuk

Klinika Kardiologii Uniwersytetu Medycznego w Białymstoku

Piśmiennictwo

  1. 1. Lip G.Y., Laroche C., Boriani G. i wsp. Sex-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: a report from the Euro Observational Research Programme Pilot survey on Atrial Fibrillation. Europace 2015; 17: 24–31.
  2. 2. Nabauer M., Gerth A., Limbourg T. i wsp. The Registry of the German Competence NETwork on Atrial Fibrillation: patient characteristics and initial management. Europace 2009; 11: 423–434.
  3. 3. Łopatowska P., Tomaszuk-Kazberuk A., Mlodawska E. i wsp. Ma­nagement of patients with valvular and non-valvular atrial fibrillation in Poland: results from Reference Cardiology University Centre. Cardiol. J. 2015; 22: 296–305.
  4. 4. Nieuwlaat R., Capucci A., Camm A.J. i wsp. Atrial fibrillation ma­nagement: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur. Heart J. 2005; 26: 2422–2434.
  5. 5. Kakkar A.K., Mueller I., Bassand J.P. i wsp. 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; 8: e63479.
  6. 6. Andersson T., Magnuson A., Bryngelsson I.L. i wsp. All-cause mortality in 272,186 patients hospitalized with incident atrial fibrillation 1995–2008: A Swedish nationwide long-term case-control study. Eur. Heart J. 2013; 34: 1061–1067.
  7. 7. Kirchhof P., Ammentorp B., Darius H. i wsp. 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.
  8. 8. Farmakis D., Pipilis A., Antoniou A. i wsp. Clinical profile and therapeutic management of patients with atrial fibrillation in Greece: Results from the Registry of Atrial Fibrillation to Inves­tigate New Guidelines (RAFTING). Hellenic J. Cardiol. 2013; 54: 368–375.
  9. 9. Avgil Tsadok M., Jackevicius C.A., Rahme E. i wsp. Sex differences in stroke risk among older patients with recently diagnosed atrial fibrillation. JAMA 2012; 307: 1952–1958.
  10. 10. Dagres N., Nieuwlaat R., Vardas P.E. i wsp. Gender-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: a report from the Euro Heart Survey on Atrial Fibrillation. J. Am. Coll. Cardiol. 2007; 49: 572–577.

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