Atrial Fibrillation In Australia Research Articles

Time Trends in Stroke Risk Management Among Patients With Atrial Fibrillation in Australia Between 2011–2019

Time Trends in Stroke Risk Management Among Patients With Atrial Fibrillation in Australia Between 2011–2019

An Observational Study of Clinical and Health System Factors Associated With Catheter Ablation and Early Ablation Treatment for Atrial Fibrillation in Australia.

To investigate clinical and health system factors associated with receiving catheter ablation (CA) and earlier ablation for non-valvular atrial fibrillation (AF). We used hospital administrative data linked with death registrations in New South Wales, Australia for patients with a primary diagnosis of AF between 2009 and 2017. Outcome measures included receipt of CA versus not receiving CA during follow-up (using Cox regression) and receipt of early ablation (using logistic regression). Cardioversion during index admission (hazard ratio [HR] 1.96; 95% CI 1.75-2.19), year of index admission (HR 1.07; 95% CI 1.05-1.10), private patient status (HR 2.65; 95% CI 2.35-2.97), and living in more advantaged areas (HR 1.18; 95% CI 1.13-1.22) were associated with a higher likelihood of receiving CA. A history of congestive heart failure, hypertension, diabetes, and myocardial infarction were associated with a lower likelihood of receiving CA. Private patient status (odds ratio [OR] 2.04; 95% CI 1.59-2.61), cardioversion during index admission (OR 1.25; 95% CI 1.0-1.57), and history of diabetes (OR 1.6; 95% CI 1.06-2.41) were associated with receiving early ablation. Beyond clinical factors, private patients are more likely to receive CA and earlier ablation than their public counterparts. Whether the earlier access to ablation procedures in private patients is leading to differences in outcomes among patients with atrial fibrillation remains to be explored.

Thirty-Day Unplanned Readmissions Following Hospitalisation for Atrial Fibrillation in Australia and New Zealand

Atrial fibrillation (AF) is a leading cause of hospitalisations, yet little is known about 30-day readmissions following discharge despite increasing policy focus on reducing readmissions. We assessed the rate, timing, causes and predictors of 30-day unplanned readmission following an acute and elective AF hospitalisation using population-wide data. We studied all patients hospitalised for AF from 2010 to 2015 at all public and most private hospitals in Australia and New Zealand. The main outcome measures were unplanned readmissions within 30 days of discharge, primary diagnosis associated with these readmissions, and their predictors as modelled by logistic regression. Among 301,654 patients hospitalised for AF (mean age 69.2±13.6 yrs, 55.6% female, 65.2% acute presentations), 29,750 (9.9%) experienced an unplanned readmission within 30 days with 62.6% occurring by 14 days. Unplanned readmissions occurred more frequently following an acute versus elective AF hospitalisations (12.5% vs 4.9%, p<0.001). The most common diagnoses associated with readmissions were recurrence of AF (n=9,890, 33.2%), and preventable conditions including heart failure (n=2,683, 9.0%), pneumonia (n=724, 2.4%) and acute myocardial infarction (n=510, 1.7%). A higher risk of 30-day readmission was associated with congenital cardiac/circulatory defect (OR 2.18, CI 1.44-3.30), congestive heart failure (OR 1.34, CI 1.30-1.39), and arrhythmia/conduction disorders (OR 1.25, CI 1.21-1.28). Almost 1 in 10 AF hospitalisations resulted in unplanned readmission within 30-days, mostly for AF recurrence. Improved clinical management of AF and transitional care planning are required to reduce unplanned readmissions following AF hospitalisations.

Cost of Anticoagulation for Non-Valvular Atrial Fibrillation in Australia

Objectives: Since 2013, non-vitamin K antagonist oral anticoagulants (NOACs) have surpassed Warfarin to become the mainstay treatment of non-valvular atrial fibrillation (AF) in Australia. We examine the analogous change in cost of anticoagulation over the past 5 years. Methods: Data were extrapolated from the Pharmaceutical Benefits Scheme (PBS) and Medicare Australia. We examined the total number of scripts and cost of Warfarin and all NOACs- Apixaban, Rivaroxaban, Dabigatran- that were available for non-valvular AF from September 2013 until October 2018. Month-to-month comparisons were made between the cost of all NOACs and Warfarin. INR testing cost was examined over the same period. Results: NOAC prescription in Australia has continued to rise with a 3530% increase from September 2013 to October 2018 corresponding to a 42.8% decline in Warfarin use. Our study further demonstrates a 31.9% decrease in INR testing. Apixaban has now exceeded Rivaroxaban as the most commonly prescribed NOAC (48.2% vs. 40.4%) for non-valvular AF. With the increasing use of NOACs, cost has also increased proportionately by 3400% from $790,569 in September 2013 to $26,902,194 in October 2018. This has corresponded with a 21.9% decrease in cost of Warfarin and INR testing from $7,493,898 to $5,855,804. Conclusions: NOACs have become the drugs of choice for stroke prevention in non-valvular AF in Australia. While use of NOACs has increased cost to the government, cost of Warfarin and INR testing has declined and costs are expected to decrease further when NOAC patents expire in 2020.

Trends in outpatient anti-arrhythmic prescriptions for atrial fibrillation and left atrial ablation in Australia: 1997-2016.

An important aspect of atrial fibrillation (AF) management is the decision whether to adopt a rate or rhythm control strategy. Options for the latter include oral anti-arrhythmic drugs (AAD) or catheter ablation. To describe the trends in rhythm control for AF in Australia between 1997 and 2016. We conducted a retrospective study using prospectively collected data between 1997 and 2016 from the Pharmaceutical Benefit Scheme and Medicare Benefit Schedule websites, which, respectively, contain information pertaining to public AAD prescriptions and rebatable AF ablation procedures performed in Australia. Sotalol and amiodarone remain the most commonly prescribed AAD in Australia, although their use is decreasing. Rates of catheter ablation for AF continue to rise annually with a 48-fold increase from 71 to 3480 since 1997. A rhythm control strategy is frequently utilised for AF management in Australia. Consistent with international guidelines which advocate safety over efficacy when choosing a rhythm control strategy, the prescriptions of amiodarone have been consistently decreasing since 2002, whereas sotalol and flecainide prescriptions have largely increased, with a peak in 2015. Catheter ablation per capita has burgeoned 36-fold.

NOACs Now Mainstream for the Use of Anticoagulation in Non-Valvular Atrial Fibrillation in Australia

The management of stroke risk in patients with non-valvular atrial fibrillation has changed over the past few years. This change has occurred due to the introduction of novel oral anticoagulants (NOACs) such as apixaban, rivaroxaban and dabigatran for the management of non-valvular atrial fibrillation. These agents have shown comparable stroke risk reduction to warfarin in large international multicentre trials [1-3]. This has changed the clinical practice of many treating physicians since their introduction from 2011 to 2013. The purpose of this review was to highlight the now mainstream use of NOAC administration in preference to warfarin, by comparing the trends in the number of prescriptions filled since all three forms of oral anti-coagulant became available in 2013. These agents are being increasingly prescribed due to their ease of use compared to warfarin, which not only requires ongoing monitoring due to narrow therapeutic range but also has many drug and food interactions. Since November 2015, NOACs have become the mainstream choice for anticoagulation in atrial fibrillation likely given their ease of use compared to warfarin. The use of each anticoagulant remains divergent with the use of warfarin continuing to decrease.

196Trends in hospital admissions for atrial fibrillation in Australia: a relentless rise

196Trends in hospital admissions for atrial fibrillation in Australia: a relentless rise

Anticoagulation Trends for Atrial Fibrillation in Australia Over the Last 5 Years

Anticoagulation Trends for Atrial Fibrillation in Australia Over the Last 5 Years

A High HASBLED Score Identifies Poor Warfarin Control in Patients Treated for Non-Valvular Atrial Fibrillation in Australia and Singapore.

Warfarin reduces stroke risk in atrial fibrillation (AF) patients. The quality of warfarin control, measured by time in therapeutic range (TTR), impacts outcome and adverse events. One tool evaluating risk of adverse events and potential warfarin control would simplify risk-benefit assessment of warfarin. Recently, HASBLED was demonstrated effective for this purpose, but this was in well-controlled patients with deep vein thrombosis. HASBLED as a predictor of warfarin control has not been validated in other populations including differing indications, warfarin control levels and ethnicities. The aim of this study was to determine whether HASBLED can predict warfarin control in patients with AF in Australia and Singapore. Retrospective data were collected for patients receiving warfarin between January and June 2014 in Australia and Singapore. Patient data were used to calculate HASBLED at the start and end of the study period. TTR was calculated for each patient, and mean TTR used for analysis to stratified HASBLED scores. Of the 4370 patients, there were 3199 in Australia and 1171 in Singapore with mean TTRs of 82% and 58%, respectively. At the start of the study, a HASBLED score ≥3 predicted significantly lower TTR in Singapore, whilst at the end of the study, this score identified patients with poor control in both Australia and Singapore. A HASBLED score ≥3 in patients treated with warfarin can differentiate significantly lower TTRs in Australian and Singapore patients with AF. HASBLED may assess bleed risk and warfarin control, identifying patients at high risk of poor warfarin outcome requiring additional INR monitoring or alternative anticoagulation.

The Utilization of Antithrombotic Therapy in Older Patients in Aged Care Facilities With Atrial Fibrillation

Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld in older people due to the risk and fear of hemorrhage. Although the underutilization of anticoagulants in patients with AF has been demonstrated internationally, few studies have been conducted among aged care residents. The aim of this study was to determine the utilization of anticoagulants among people with AF residing in aged care facilities. We performed a non-experimental, retrospective analysis designed to evaluate antithrombotic usage in patients with AF in Australia residing in aged care facilities, using data collected by pharmacists while performing Residential Medication Management Reviews (RMMRs). The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on the CHADS2, CHA2DS2-VASc, and HAS-BLED risk stratification schemes in consideration of documented contraindications to treatment. Predictors of anticoagulant use were determined using multivariate logistic regression. A total of 1952 RMMR patients with AF were identified. Only 35.6% of eligible patients (CHADS2 score ≥2 and no contraindications to anticoagulants) received an anticoagulant. As age increased, the likelihood of receiving an anticoagulant decreased and the likelihood of receiving an antiplatelet or no therapy increased. In patients at high risk of stroke (CHADS score ≥2), utilization of anticoagulants dropped by 19.7% when the HAS-BLED score increased from 2 to 3, suggesting that physicians placed a heavier weighting on bleeding risk rather than stroke risk. Prescribing of anticoagulants was influenced to a greater extent by bleeding risk than it was by the risk of stroke. Further research investigating whether the growing availability of direct oral anticoagulants influences practice in this patient population is needed.

Changing Treatment Patterns in Atrial Fibrillation in Australia: Results From the Global Anticoagulation in the Field (GARFIELD) Registry

Changing Treatment Patterns in Atrial Fibrillation in Australia: Results From the Global Anticoagulation in the Field (GARFIELD) Registry

Seasonal Variation in Hospital Presentations for Atrial Fibrillation in Australia

Seasonal Variation in Hospital Presentations for Atrial Fibrillation in Australia

The Utilization of Antithrombotic Therapy in Older Australians With Atrial Fibrillation.

Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld due to a perceived risk of severe adverse events. The underutilization of anticoagulants in patients with AF has been demonstrated internationally, but to date, there are limited data available in the Australian context. The aim of this study was to determine the utilization patterns of anticoagulants (including novel oral anticoagulants) with respect to stroke and bleeding risk among patients with AF within the community. We performed a nonexperimental, retrospective analysis designed to evaluate antithrombotic usage for AF in Australia. The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on CHADS2, CHA2DS2-VASc and HAS-BLED risk stratification schemes. The presence of documented contraindications was used to determine the appropriateness of antithrombotic therapy. Anticoagulants were overutilized in patients at low risk of stroke and underutilized in patients at higher risk of stroke. As the HAS-BLED score increased, the likelihood of patients receiving an anticoagulant decreased regardless of CHADS2 or CHA2DS2-VASc scores.

Prevalence, incidence, risk factors and treatment of atrial fibrillation in Australia: The Australian Diabetes, Obesity and Lifestyle (AusDiab) longitudinal, population cohort study

ObjectiveWe sought to describe the prevalence, incidence, risk factors and treatment (according to stroke risk) of atrial fibrillation (AF) in the national, population-based Australian Diabetes, Obesity and Lifestyle (AusDiab) study cohort. MethodsECG data were available from 8273/11,247 participants of AusDiab study in 1999/2000 and from 5422 participants in 2004/2005. Minnesota coding was used to identify prevalent and incident cases of AF. Results90 prevalent cases of AF (14.1 per 1000) comprising 56 men (mean age 70.5±1.9years) and 34 women (aged 78.3±1.2years) were identified in 1999–2000. AF prevalence was associated with sedentary behaviour versus physically active (PR 2.0, 95% CI 1.2–3.6). 53 incident cases of AF (2.0, 95%, CI 1.5–2.6 per 1000 person–year) were subsequently identified in 2004–2005. Increased risk of incident AF was associated with male sex, obesity, history of angina, myocardial infarction and stroke. Both increased weight gain and increased weight loss appeared to be associated with increased risks of developing AF in women, while no obvious association was observed in men. Despite their high risk for stroke, anti-thrombotic therapy was observed in only 39.3% of participants with CHA2DS2-VASC scores≥2. ConclusionsThis study contributes to a better understanding of the AF burden. With the ageing population, coordinated efforts will be needed to anticipate the future health care costs related to AF and its impacts on the health care system. This will include appropriate application of anti-thrombotic therapy according to risk of thrombo-embolic events.

Cost-effectiveness of apixaban compared to warfarin in the management of atrial fibrillation in Australia

To determine the cost-effectiveness of apixaban versus warfarin in patients with atrial fibrillation (AF) with a moderate to severe risk of stroke, from an Australian government-perspective. A decision-analytic Markov model was constructed to assess the cost-effectiveness of apixaban versus warfarin, based on data from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in AF (ARISTOTLE) trial. The model comprised five health states: 'Alive, no major bleeding or stroke', 'Alive, no major bleeding, post stroke/systemic embolism', 'Alive, post major bleeding, no stroke', 'Alive, post-major bleeding and stroke' and 'Dead'. Disease cost data was derived from the North-East Melbourne Stroke Incidence Study and the Australian Refined Diagnose Related Groups. Costs of medications were based on data from the Pharmaceutical Benefit Scheme. Utility data was derived from published sources, and an annual discount rate of 5% was applied to costs and benefits. The main outcome of interest was incremental cost-effectiveness ratios per life year gained (LYG) and quality adjusted life years (QALYs) gained. Over 20 years, in the sample of 1000 subjects the model predicted that compared to warfarin, apixaban led to a (discounted) of 0.33 LYG and 0.31 QALYs gained, at a net cost of $4,308 per-person. These equated to ICERs of $AUD12, 914 per LYG and $AUD13, 679 per QALY gained. Probabilistic sensitivity analysis demonstrated that apixaban was cost-effective at 99.0% probability using willingness to pay thresholds of $AUD45 000 per LYG and QALY. Compared to warfarin, apixaban is likely to represent a cost-effective means of preventing stroke-related morbidity and mortality in patients with AF.

National Heart Foundation of Australia consensus statement on catheter ablation as a therapy for atrial fibrillation

Atrial fibrillation (AF) is estimated to affect 1%-2% of the population. It is increasing in prevalence and is associated with excess mortality, considerable morbidity and hospitalisations. AF is responsible for a significant and growing societal financial burden. Catheter ablation is an increasingly used therapeutic strategy for the management of AF; however, some confusion exists among those caring for patients with this condition about the role and optimal use of ablative treatments for AF. Our aim in this consensus statement is to provide recommendations on the use of primary catheter ablation for AF in Australia, on the basis of current evidence. Our consensus is that the primary indication for catheter ablation of AF is the presence of symptomatic AF that is refractory or intolerant to at least one Class 1 or Class 3 antiarrhythmic medication. In selecting patients for catheter ablation of AF, consideration should be given to the patient's age, duration of AF, left atrial size and the presence of significant structural heart disease. Best results are obtained in younger patients with paroxysmal AF, no structural heart disease and smaller atria. Ablation techniques for patients with persistent AF are still undergoing evaluation. Discontinuation of warfarin or equivalent therapies is not considered a sole indication for this procedure. After AF ablation, anticoagulation therapy is generally recommended for all patients for at least 1-3 months. Discontinuation of warfarin or equivalent therapies after ablation is generally not recommended in patients who have a CHADS 2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes, 1 point each; prior stroke or transient ischaemic attack, 2 points) of ≥ 2.

Treating Atrial Fibrillation: Pulmonary Vein Isolation with the Cryoballoon Technique

Cryoballoon ablation is a recently introduced technique to isolate the pulmonary veins in patients with atrial fibrillation (AF). It can potentially reduce procedural times and serious complications associated with radiofrequency ablation. We present data for 200 consecutive patients who underwent cryoballoon ablation for symptomatic AF with a mean follow-up of 16 months. Over 214 procedures that involved cryoballoon technique the mean procedure and fluoroscopy times fell to 130 and 30 min, respectively. 93.6% of pulmonary veins targeted were isolated with the cryoballoon only and 97.7% could be isolated with the addition of a radiofrequency ablation catheter. At one year 70% of patients in the paroxysmal AF group and 59% of patients in the persistent AF group were free from symptomatic recurrence. Three percent of patients experienced phrenic nerve palsy that persisted beyond the procedure. The major complication rate in this study was 0.9%. This represents the earliest and largest experience with cryoballoon ablation for AF in Australia. The major complication rate was low with no pulmonary vein stenosis, atrio-oesophageal fistula, stroke or cardiac tamponade in this series. The majority of patients were free from symptomatic recurrence at two years follow up.

Atrial Fibrillation in Australia – Results from the Garfield Study

Atrial Fibrillation in Australia – Results from the Garfield Study

Ten-year Trends in the Use of Catheter Ablation for Treatment of Atrial Fibrillation Versus the Use of Coronary Intervention for the Treatment of Ischaemic Heart Disease in Australia

Background: We examined the 10-year trends in the use of catheter ablation procedures for atrial fibrillation (AF) and compared it to the use of percutaneous coronary intervention (PCI) for the management of ischaemic heart in Australia. Methods: This was a retrospective review of publically available data from 2000 to 2010 on AF ablations and PCIs performed from the Australian Institute of Health, Welfare and Aging (AIHW), Medicare Australia database (MA), and from local records at a high volume electrophysiology and coronary intervention tertiary referral center at The Royal Melbourne Hospital (RMH). We studied the yearly trends in number of AF ablations and PCIs over a 10-year period. Results: Over the 10 year period, AF ablations increased by 31% and 29%/year from the AIHW and MA databases respectively (Ptrend over 10 years < .001). Whilst PCIs over the same time period increased by 5% and 7.9%/year (Ptrend over 10 years < .001), the percentage increase in AF ablations was significantly higher (P < .001). Local RMH data showed a 43% annual increment in AF ablations (Ptrend over 10 years < 001) however PCIs over the same time period did not change significantly (Ptrend over 10 years = .23). Increase in AF ablations was significantly higher than PCIs at RMH (P < .001). Conclusions: There is an exponential increase in the numbers of AF ablations annually that outstrips the rate of growth of PCI in Australia over the past decade. This data suggests that significant further work is needed to improve infrastructure, training and funding for catheter ablation of AF in Australia.

PCV60 Cost-Effectiveness of Dabigatran for the Prevention of Stroke in Patients with Non-Valvular Atrial Fibrillation in Australia

PCV60 Cost-Effectiveness of Dabigatran for the Prevention of Stroke in Patients with Non-Valvular Atrial Fibrillation in Australia