Oral anticoagulation therapy (OAT) is the cornerstone of stroke prevention in nonvalvular atrial fibrillation (NVAF) . Current registries of anticoagulation therapy (ACT) for NVAF are a priority in high-income countries [2, 3]. However, in upper middle-income countries like Mexico, there is scarce epidemiological data about OAT for NVAF [4, 5].
CARMEN-AF (Registry of Atrial Fibrillation and Embolic Risk in Mexico) is a nationwide, industry-independent registry, developed as a means to bridge the information gap about OAT for NVAF in Mexico . Herein, we report the results of the CARMEN-AF Registry, analyzed by age, AF type, and thromboembolic risk.
CARMEN-AF is an ongoing, observational, longitudinal, multi-center, nationwide registry of OAT in NVAF in Mexico. A full list of the investigators of the Registry could be consulted in the Appendix A of this article. The protocol has already been published . An English version of the Registry of Atrial Fibrillation and Embolic Risk in Mexico (CARMEN-AF) could be consulted in Supplementary Material. Mexico’s economic status as an upper-middle income country is based on the 2013 World Bank Classification according to gross national income per capita . A total of 1,423 consecutive patients were enrolled in a three-year period (September 19, 2014 – December 18, 2017).
Eligible patients were at least 18 years old, with one or more risk factors for thromboembolism evaluated by CHA2DS2-VASc score and diagnosed with NVAF at least 6 months prior to their inclusion. Patients were included independent of anti-thrombotic therapy (ATT) (antiplatelet drugs [APD], vitamin K antagonists [VKA] or direct oral anticoagulants [DOAC] available in Mexico [dabigatran, rivaroxaban, and apixaban]). We used cross-sectional data obtained at patient recruitment. Physicians performed data collection at regular clinic visits using a paper-based case report form, with subsequent capture in an electronic case report form for data storage.
A table specifying the centers that participated, grouped by state (geographical distribution), and details about the type of clinic (public/private, second/third level), and the type of practice (the specialty of the center coordinator) can be consulted in the supplementary material. It also includes the type of residence of the patients (urban or rural). All patients were treated in urban centers (mostly by cardiologists), representing 29 states of the Mexican Republic. All patients were assessed at an initial clinical visit with a complete medical history and physical examination (Table 1).
|Center||State||Level of care||Type||Specialty of the coordinator||Type of residency of the patients (Urban, rural, both)|
|Sociedad Cardiovascular de Aguascalientes||Aguascalientes||Third||Private||Electrophysiologist||Urban|
|Hospital Regional No1 IMSS, Tijuana||Baja California||Second||Public||Cardiologist||Both|
|Hospital Angeles Tijuana||Baja California||Third||Private||Cardiologist/Internist||Urban|
|Plaza Medical||Baja California||Third||Private||Cardiologist||Urban|
|Hospital General ISSSTE, La Paz||Baja California sur||Third||Public||Cardiologist/Internist||Urban|
|Hospital GE ‘Dr Javier Buenfil Osorio’ INDESALUD||Campeche||Third||Public||Cardiologist||Both|
|Instituto Nacional de Cardiologist ‘Ignacio Chavez’||Mexico City||Third||Public||Electrophysiologist||Both|
|Hospital de Especialidades, Centro Medico Nacional ‘La Raza’ IMSS||Mexico City||Third||Public||Electrophysiologist||Both|
|Hospital de Cardiologist del Centro Medico Nacional ‘Siglo XXI’ IMSS||Mexico City||Third||Public||Electrophysiologist||Both|
|Hospital General de Mexico||Mexico City||Third||Public||Electrophysiologist||Urban|
|Instituto Nacional de Ciencias Medicas y Nutricion ‘Salvador Zubiran’||Mexico City||Third||Public||Neurologist||Urban|
|Unidad Medica de Alta Especialidad No71 IMSS, Coahuila||Coahuila||Third||Public||Cardiologist||Urban|
|Hospital General de Zona No 10, Manzanillo||Colima||Second||Public||Cardiologist/Internist||Urban|
|Hospital General de Zona No 1 IMSS, Durango||Durango||Second||Public||Cardiologist/Internist||Both|
|ISSEMYM Toluca||Estado de Mexico||Third||Public||Electrophysiologist||Urban|
|Hospital Angeles Leon||Guanajuato||Third||Private||Electrophysiologist||Both|
|Hospital General de Acapulco||Guerrero||Third||Public||Cardiologist/Internist||Both|
|Hospital General de Pachuca||Hidalgo||Third||Public||Cardiologist/Internist||Both|
|Hospital Civil de Guadalajara||Jalisco||Third||Public||Cardiologist/Internist||Urban|
|Hospital General de Uruapan||Michoacan||Second||Public||Cardiologist||Both|
|Instituto Nacional de Trasplantes||Morelos||Second||Private||Cardiologist/Internist||Urban|
|Instituto de Cardiologist y Medicina Vascular Hospital Zambrano, Tec Salud||Nuevo Leon||Third||Private||Electrophysiologist||Urban|
|Hospital Regional de Alta Especialidad de Oaxaca||Oaxaca||Third||Public||Cardiologist. Internist||Urban|
|Hospital General del Sur de Puebla||Puebla||Third||Private||Electrophysiologist||Urban|
|Hospital Angeles de Puebla||Puebla||Third||Private||Electrophysiologist||Urban|
|Instituto del Corazon Queretaro||Queretaro||Third||Private||Internist||Both|
|Hospital General de Zona No3 IMSS||Quintana Roo||Second||Public||Cardiologist||Both|
|Hospital Central ‘Dr Ignacio Morones Prieto’||San Luis Potosi||Third||Public||Cardiologist||Both|
|Torre Medica Olivos||San Luis Potosi||Primer||Private||Cardiologist||Urban|
|Hospital Civil de Culiacan||Sinaloa||Public||Cardiologist||Both|
|Hospital General de Culiacan||Sinaloa||Second||Public||Cardiologist/Internist||Both|
|Centro Medico Nacional del Noroeste IMSS||Sonora||Third||Public||Cardiologist||Both|
|Hospital Regional de Alta Especialidad ‘Juan Graham Casasus’||Tabasco||Third||Public||Cardiologist/Internist||Both|
|Hospital Regional de PEMEX Ciudad Madero||Tamaulipas||Third||Public||Cardiologist||Both|
|Unidad Medica de Alta Especialidad No 14 IMSS||Veracruz||Third||Public||Cardiologist||Both|
|Star Medica Merida||Yucatan||Third||Private||Cardiologist||Urban|
|Hospital ‘San Agustin’||Zacatecas||Third||Private||Cardiologist||Both|
Data was analyzed using SPSS v. 22.0. Demographic differences among continuous variables with normal distribution were examined using Student’s t-test; Wilcoxon signed-rank test was used when variables failed normality test. Categorical variables were analyzed using Chi-square test, either Fisher’s exact test or Yates’s correction for continuity. A 2-tail test with a P value <0.05 was considered statistically significant.
Informed consent was obtained from each patient and the study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the institution’s human research committee.
A total of 1,423 consecutive patients were enrolled in a three-year period (September 19, 2014–December 18, 2017). Mean age of participants was 69 ± 13 years old. 731 (51.4%) were male. Complete demographic characteristics are shown in Table 2.
|All(n = 1,423)||Male(n = 731)||Female(n = 692)||P*|
|Age, years ± SD||69 ± 13||68 ± 13||70 ± 12||=0.002|
|Weight, kg ± SD||75 ± 16||80 ± 15||69 ± 14||<0.0001|
|Body Mass Index, kg/m2 ± SD||28.5 ± 5.0||28.4 ± 4.6||28.7 ± 5.4||ns|
NVAF was paroxysmal in 37.3% of the cases, persistent in 22.1%, permanent in 40.6%; AF was asymptomatic in 59.4% of patients. The most prevalent comorbidities (Table 3) in patients with NVAF were hypertension (72.5%), diabetes (28.4%), heart failure (23.6%) and smoking (16.4%).
|(%)||All (n = 1,423)||Male (n = 731)||Female (n = 692)||P*|
|Coronary Artery Disease||7.1||9.7||4.3||<0.0001|
|Obstructive sleep apnea||3.9||5.2||2.6||=0.008|
|Peripheral artery disease||1.8||1.0||2.7||=0.010|
Related to ATT, 16.6% of patients were not receiving any; 19.4% were receiving APD, and 63.9% of the patients were receiving oral anticoagulants (VKA = 416, 29.2%; DOAC = 493, 34.6%). OAT was either monotherapy (56.9%) or combined with one or two APD (7.2%) (Table 4).
|Antithrombotic therapy according to AF type|
|(%) P = 0.037*||All (n = 1,423)||Paroxysmal (n = 531)||Persistent (n = 314)||Permanent (n = 578)|
|Anticoagulant + Antiplatelet||5.7||4.9||8.9||4.7|
In accordance to AF type (paroxysmal, persistent, and permanent), suboptimal ATT (no ATT or just APD treatment) was observed in 40.3% of patients in the paroxysmal group, 35.7% in the persistent group, and 32.5% in the permanent group. There was a statistically significant difference between treatments when the groups were compared. (P = 0. 026) (Figure 1).
The thromboembolic risk was assessed using CHA2DS2-VASc score (moderate risk = 1 point; high risk ≥2 points). No significant difference was observed on ATT between moderate and high thromboembolic risk subjects. Interestingly, inadequate ATT was observed in 36.4% of high thromboembolic risk patients: 20.1% were treated with APD and 16.3% did not receive any treatment (Figure 2).
As the CHA2DS2-VASc score classifies thromboembolic risk according to age, patients were divided into three groups (Figure 3). In the group of patients younger than 65 years old, 70.4% received OAT (DOAC 34.2%, VKA 36.2%), 15.2% received APD and 14.3% did not receive ATT. In the 65–74 years old group, 66.4% of patients received OAT (DOAC 36.0%, AVKs 30.4%), 17.8% received APD, and 15.9% did not receive ATT. In the group of patients’ ≥75 years old, 56.4% received OAT (DOAC 33.9.0%, VKA 22.5%), 24.5% were on APD, and 19.0% received no treatment.
There was a significant difference in HAS-BLED score between men and women; it was higher in men (1.82 ± 1.0 vs 1.71 ± 0.9; P = 0.032). According to bleeding risk, more women had a low risk of bleeding than men (9.7% vs 6.3%, P = 0.012), while more men had a high risk (20.8% vs 16.8%, P = 0.030) .
Of the studied population, 9.5% of women and 19.2% men at high risk of bleeding (HAS-BLED score = ≥3) did not receive any antithrombotic therapy (P = 0.021).
Patients with AF have 5 times greater risk of stroke than the general population . There is significant evidence that the use of oral anticoagulants, both VKA and DOAC, reduce the risk of stroke in patients with NVAF [9, 10, 11, 12]. Thromboembolic risk assessment should be performed at diagnosis using CHA2DS2-VASc score, and OAT should be started in patients with moderate and high risk of thrombosis (score ≥ 2) .
Clinical registries are proven to evaluate the correct application of treatment guidelines.
CARMEN-AF was designed to find out current information about the status of OAT for NVAF in Mexico. The main finding of this registry was that despite most of the patients in our cohort (85.6%) were classified as high thromboembolic risk according to CHA2DS2-VASc score (≥2), 35.8% of the total population diagnosed with NVAF were not receiving OAT or only received APD, a suboptimal therapy.
It was also found a trend in the use of OAT according to age. In Mexico, OAT is less commonly prescribed for elderly patients, despite that age is a well-known risk factor for thromboembolism; this conduct may be related to the fear of hemorrhagic complications in this group of patients according to HAS-BLED score . Elderly patients who did receive OAT were more likely to be prescribed with a DOAC instead of VKA, probably due to better adherence and ease of use of DOAC .
Data collected by CARMEN-AF shows similarities with other large-scale NVAF registries. In Mexico, an upper middle-income country, hypertension remains the main comorbidity, just as in GLORIA-AF and GARFIELD registries. Also, the proportion of participants with high thromboembolic risk as assessed by CHA2DS2-VASc scores was very similar among the three registries (GLORIA-AF 86.1%; GARFIELD 84.3%; CARMEN-AF 85.6%). Finally, in Mexico DOAC are preferred as OAT in contrast with some other countries in Latin America, in which VKA remains the therapy of choice for prevention of thromboembolic complications in NVAF [15, 16, 17].
In order to understand differences among registries, we must remember that CARMEN-AF had a greater proportion of permanent NVAF (40.6%), while GLORIA-AF reported only 11.1% and GARFIELD 13.1% (P < 0.0001). Also, the amount of patients left untreated in CARMEN-AF (16.6%) is greater than GARFIELD (12.3%) and GLORIA-AF (7.8%) global cohorts, as well as GLORIA-AF Latin America cohort (4.2%) [15, 16, 18]. Significant differences in treatment were observed between the three registries (P < 0.0001).
CARMEN-AF was based on the prescription of antithrombotic therapy by different specialists; therefore, our data may not apply to other healthcare givers.
According to protocol, this survey recruited only patients with CHA2DS2-VASc≥ 1. Thus, no data on patients with score zero (low risk of stroke) were available.
Both patients and physicians knew they were participants of a registry; this might have led to higher overall anticoagulation rates compared with general population.
Unfortunately, the socioeconomic status as a variable is not available for the entire study.
CARMEN-AF demonstrated a suboptimal thromboprophylaxis in NVAF in Mexico, an upper-middle income country, accounting for relevant differences with respect to high-income countries. Identification of gaps in the implementation of global guidelines between countries is the first step towards the objectives of the World Heart Federation Roadmap for NVAF.
The additional files for this article can be found as follows:Appendix A
Full list of the investigators and their participating centers of the Registry of Atrial Fibrillation and Embolic Risk in Mexico (CARMEN-AF). DOI: https://doi.org/10.5334/gh.767.s1Supplementary material
A full English version of the design of the Registry of Atrial Fibrillation and Embolic Risk in Mexico (CARMEN-AF), to assist our global audience to a better approaching to the original article published in Spanish in 2016 in Archivos de Cardiología de México. DOI: https://doi.org/10.5334/gh.767.s2
AF = Atrial fibrillation
APD = Antiplatelet drugs
ATT = Antithrombotic therapy
DOAC = Direct oral anticoagulants
NVAF = Nonvalvular atrial fibrillation
OAT = Oral anticoagulation therapy
VKA = Vitamin K antagonists
The authors would like to thank MedicaWeb for the technical support provided in the development of the CARMEN-AF Registry, as well as the Mexican Society of Cardiology for their endorsement.
Bayer, Boehringer-Ingelheim, and Pfizer unrestrictedly support the CARMEN-AF Registry, only for academic purposes. They did not intervene in the design of the CARMEN-AF Registry or in the elaboration of this material.
http://www.clinicaltrials.gov. Unique identifier: NCT02334852.
Doctors González-Hermosillo and Manlio F. Márquez have participated in other industry-sponsored registries and have been speakers for some companies that supported the CARMEN-AF Registry.
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