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Abstract

Objective:

The authors aimed at reporting on whether or not primary care doctors follow atrial fibrillation (AF) treatment protocols, and on the mental distress of such patients.

Methods:

A total of 138 patients with first detected or recurrent AF were examined in a health center. Demographic data were collected and their lifestyle and medical history for rhythm-related pathologies and chronic medication were investigated. Physical examination, electrocardiogram (EKG), and in selected cases, lab analysis were carried-out. CHADS₂ index was used for assessing the stroke risk in patients with AF, while the General Health Questionnaire-12 (GHQ-12) for personal health perception was performed in all patients.

Results:

According to CHADS₂ the majority of the patients had at least 1 risk factor and half of those receiving oral vitamin K antagonists presented an out-of-range international normalized ratio (INR). In 24 cases, patients used both aspirin and oral anticoagulants, while in 41 cases, medication was corrected according to index. GHQ-12 seemed to be significantly worse in paroxysmal and persistent cases, as well as in women with recurrent AF. Many paroxysmal AF patients under 75 years continued caffeine intake, whereas an extensive use of benzodiazepines was noticed in the majority of patients.

Conclusions:

Shortages and limitations of the peripheral or rural units and health centers and inadequate knowledge and application of the guidelines, seemed to be major factors responsible for mismanaging AF patients. More education in prehospital cardiology may contribute in improving management of arrhythmias in primary care.

Keywords

atrial fibrillation stroke mental disorders primary care

Introduction

The prevalence of atrial fibrillation (AF) has been estimated in 1% of the general population of Sweden,¹ while according to Sudlow et al,² AF was present in 4.7% of the elderly in the community. A total of 16% of all ischemic strokes are related to nonvalvular AF, increasing to one third in patients over 75 years.³

Evaluation and treatment should be a priority to avoid sudden death from life-threatening arrhythmias, and to prevent ischemic strokes, minimize symptoms, and relieve patients from anxiety.⁴ Psychological distress such as depressive symptoms and/or anxiety have been correlated to recurrent arrhythmias, resulting in serious implications for health and quality of life.⁵

Prompt diagnosis and referral when necessary, follow-up, active therapy determination, patient support, and awareness of the population area and its associated risk factors are elements of great significance for the management of arrhythmias in primary health care (PHC).

Our study aimed at reporting on whether or not primary care doctors follow AF treatment protocols, and on the mental distress of such patients in a health center.

Material and Methods

Setting

The study was conducted at a rural-type health center in Northern Greece (catchment area of about 22 000 inhabitants), operating 24 hours a day. During daylight, patients are normally assigned to their own general practitioners (GPs) and emergencies are managed by them. Late afternoon and night shifts are covered in a circular way (every GP has a certain number of night shifts monthly) and GPs share patient data. Seven trainees or GP specialists participated in the present study.

AF Classification

Arrhythmias were divided into “first detected” and “recurrent,” in accordance with recent guideline recommendations.^6,7 Recurrent cases were further classified as follows:

Paroxysmal, if it terminated spontaneously within 7 days.

Persistent, if it did not self-terminate or lasted longer than 7 days (without cardioversion).

Permanent, in case of long-standing (over a year) arrhythmias, which were not successfully terminated by cardioversion or no cardioversion was attempted.

Recruitment

A total of 212 patients with arrhythmia symptoms (dyspnoea, palpitations, dizziness, chest discomfort, etc) or asymptomatic symptoms with a history of arrhythmia were examined and electrocardiograms (EKGs) were conducted to distinguish AF cases.^6,7 Both first detected and recurrent cases were included in the study. Special consideration was given to atrial flutter (AFL), as it can precede or coexist with AF. Uncertain cases were included in the sample and diagnosis was later confirmed by a referral to a cardiologist.

The exclusion criteria were as follows:

Patients with arrhythmias other than AF; confirmed AFL cases were excluded as well.

Arrhythmias or conditions requiring urgent assistance and transport to hospital, such as:

life-threatening arrhythmias;

patients with vertigo, risk of syncope, atrial fibrillation with high rate ventricular response, serious cardiovascular, hematologic, or lung disease;

serious gastroenterological, neurological, liver, endocrinological diseases; and/or

serious primary psychiatric or neurological disorders.

Inability to comprehend the questionnaire because of linguistic or cultural limitations or cognitive impairments.

Measures and Procedures

A questionnaire was used with queries about demographics, lifestyle, arrhythmia-related diseases (hypertension, thyrotoxicosis, ischemic heart disease, acute fever), and chronic medication (rhythm and rate control drugs, antithrombotic agents, etc). Heavy caffeine intake was considered as the consumption of >4 cups per day,⁸ while at-risk drinking was determined as >4 alcohol units per day or >14 per week for men and >3 units per day or >7 per week for women.⁹

Blood pressure and temperature were measured, and a physical exam, auscultation, and a 12-lead EKG were performed. Patients’ previous EKGs were used to distinguish recurrent arrhythmias from newly detected ones. It should be mentioned that hard copies of EKGs are distributed compulsory to all patients of the health center and are attached to their personal health booklet. Lab analyses (CBC, thyroid, biochemical control) were carried out when necessary.

Treatment strategy for recurrent AF/AFL patients was based on the CHADS₂ index. One point each was assigned for congestive heart failure, hypertension, age ≥ 75, and diabetes mellitus, while 2 points were counted for prior stroke or transient ischemic attack.¹⁰ According to the index, zero-score patients should initiate acetylsalicylic acid (ASA). For a score of 1, ASA or oral vitamin K antagonists (OVKAs) are recommended, and for scores of 2 or more, OVKAs are essential (with international normalized ratio [INR] range between 2 and 3). Target INR range was modified to 1.6 to 2.5 for patients over 74 years because of an increased risk of both thromboembolic and hemorrhagic stroke.^6,11

Finally, the brief and widely used Greek version of the General Health Questionnaire-12 (GHQ-12) was used to evaluate personal mental health perception.¹²

Referrals to cardiologists were requested in cases of uncertain diagnosis, first detected AF/AFL, or CHADS₂ score > 3.

Statistical Analysis

Data were saved in an ad hoc MySQL database using the Lumos! platform for medical data collection. Statistical analysis was performed with SPSS version 15. Checks for missing data and out-of-range values, the Kolmogorov-Smirnov test for normality, and Levene’s for homogeneity were carried-out. Frequencies and descriptive statistics were computed. Differences between 2 groups were calculated with the Mann-Whitney test and among 3 or more groups with the Kruskal-Wallis test, followed by post hoc tests for multiple comparisons, in which the Bonferroni correction was applied. Spearman’s correlation was used to determine which variables were associated, and chi-square statistics were conducted for categorical data. Reported P values are 2-tailed; a P value ≥ .05 was considered statistically nonsignificant (with the exception of multiple post hoc tests, the effects of which are reported at an adjusted level of significance).

Results

A total of 138 cases of AF/AFL were examined (mean age = 68.76, SD = 7.67; 30.4% were ≥75 years), 42 (30.4%) of which were first detected. The episode was triggered by noncardiac causes in 23 cases: 17 suffered from uncontrolled blood pressure, 4 from gastrorrhagia, and 2 from electrolytic variations. Rhythm-influencing medicines are presented in Table 1. Beta-blockers were the most frequently used rate control drugs.

Table 1.

Patient Characteristics and Pharmacological Treatment According to Type of Atrial Fibrillation

	Patients
	Men	Women	Total	Mean Age	Rhythm Control^a	Rate Control^b	Antihypertensive^c	OVKAs	Antiplatelets^d	Thyroid Therapy	Antianxiety
First detected	22	20	42	65.93	7	33	38	0	39	3	27
Paroxysmal	15	19	34	67.68	34	26	22	2	21	14	27
Persistent	15	12	27	71.63	26	23	19	13	17	5	20
Permanent	18	17	35	71.00	33	27	22	28	22	4	26
Total	70	68	138	68.76	100	109	101	43	99	26	100

Abbreviation: OVKA, oral vitamin K antagonist.

Amiodarone, propafenone, or disopyramide.

Beta-blockers, nondihydropyridine calcium-channel blockers, or digoxin.

Diuretics, dihydropyridine calcium-channel blockers, alpha-blockers, angiotensin-converting enzyme inhibitors, or angiotensin-II receptor antagonists.

Acetylsalicylic acid, ticlopidine, or clopidogrel.

Overall, 99 referrals (71.7%) were requested because of either a first detected AF/AFL or in the event that further investigation was requested. Cardiologists diagnosed 28 AFL cases.

The majority of the patients presented a CHADS₂ score ≥ 1 (Table 2). The most frequent coexisting condition of recurrent cases was the arterial hypertension (67 of 96 cases). Patients with permanent AF/AFL were more likely to receive OVKAs (OR = 12.27, 95% CI = 4.46-33.77). However, 7 patients with CHADS₂ score of zero did not receive any antiplatelet agent, 16 patients with a score of 1 used neither OVKAs nor antiplatelets, and 18 patients with a score of 2 or more were not treated with anticoagulants.

Table 2.

Stroke Risk According to CHADS₂ Index

Risk Factor	Points Assigned	Men (n)	Women (n)	Total (n)
Cardiac failure	1	12	16	28
Hypertension	1	26	41	67
Age ≥ 75	1	20	16	36
Diabetes mellitus	1	16	24	40
Stroke or transient ischemic attack	2	13	9	22

The GHQ-12 score (median = 13) was significantly affected by the temporal subtype of AF/AFL (H = 21.15, P < .001). There was a remarkable difference between recurrent cases and first detected ones (U = 1199.50, r = .32, P < .001). In particular, paroxysmal and persistent cases scored significantly worse compared with the first detected ones (Table 3). Additionally, females with permanent arrhythmia had a poorer GHQ-12 score than males. Among patients referring anxiety symptoms, those using benzodiazepines had a significantly worse score as well.

Table 3.

GHQ-12 Differences Across Different Groups

	Groups	GHQ-12 (median)	Effect Size	P Value
AF/AFL	First detected	10.50	0.51	<.001^a
	Paroxysmal	15.00
AF/AFL	First detected	10.50	0.40	.001^a
	Persistent	17.00
Recurrent AF/AFL	Men	12.50	0.31	.002
	Women	19.00
Permanent AF/AFL	Men	10.00	0.50	.002
	Women	19.00
Patients with anxiety symptoms	Receiving BZNs	13.00	0.37	.001
	Not receiving BZNs	10.00

Abbreviations: AF/AFL, Atrial Fibrillation/Flutter; BZN, Benzodiazepine.

Bonferroni-adjusted significance level = .0125.

Frequency of palpitations seemed to be correlated to GHQ-12 (r = .25, P = .003). In recurrent and particularly, in paroxysmal cases, a significantly worse score was noticed in patients reporting daily palpitation episodes (recurrent: median = 16.00; paroxysmal: median = 17.00) compared with those with monthly frequency of episodes (recurrent: median = 10.00, r = .29, P = .005; paroxysmal: median = 10.00, r = .52, P = .001).

No significant associations were noticed between palpitation episodes and alcohol consumption. Two fifths of both first detected and recurrent AF/AFL patients reported currently smoking. Patients under 75 years, who suffered from paroxysmal AF/AFL, seemed to continue heavy caffeine intake (Fisher, P = .019; OR = 5.37, 95% CI = 1.35-21.41).

Discussion

Main Findings

Our study focused on evaluating AF treatment and mental distress of patients. A total of 42 new arrhythmias were detected. Weak therapeutic practice was noticed. In 41 patients, medication was modified according to CHADS₂ index. Arrhythmia-related risk factors and mental distress were queried. Patients with paroxysmal and persistent AF/AFL had a significantly worse GHQ-12 score perhaps due to palpitations.¹³

Strengths and Limitations

Insufficient data regarding management of arrhythmias in PHC settings of Greece encouraged the realization of this study. Cases of incorrect therapeutic approach and poor primary care control were identified. Thanks to this screening, 23 patients with noncardiac causes of arrhythmia were examined and treated by ensuring the abolition of the initial cause.

AF-related ischemic strokes carry twice the risk of death compared with strokes from other causes, and although oral anticoagulation can contribute to risk reduction, there is still significant under-treatment.^14,15 In the Euro Heart Survey only 61% of the high-risk patients were treated in accordance with the guidelines, while 28% were undertreated.¹⁶

Decisions concerning the need for antithrombotic therapy should be taken after appropriate stroke and bleeding risk stratification.^6,7 CHADS₂ risk assessment revealed cases of mismanagement, as 18 patients with a score of 2 or more did not receive any anticoagulant treatment, and 24 patients used both OVKAs and ASA, though the coadministration provides no additional benefit for thromboprophylaxis.⁶ A total of 22 of the 43 patients receiving OVKAs had an out-of-range INR. Similar rates have been seen in other studies.¹⁶

The limitations of our study were as follows:

Only patients who accessed the health center were evaluated. Not all health users were examined.

Arrhythmia diagnosis was based on EKG, which is subjective to personal interpretation. Moreover, referrals were not directed to the same cardiologist.

AF was not distinguished from AFL, though anticoagulation treatment is often less needed in the case of the latter. Nevertheless, in ICD-10, both entities share the same code.¹⁷ In fact, differential diagnosis is sometimes difficult, especially in atypical AFLs, and occasionally an electrophysiological study is required.⁶ Rapid AFL may be difficult to distinguish from coarse AF and distinction can become problematic when considering only a single strip.¹⁸ Knight et al¹⁹ tested the diagnostic capabilities of 689 doctors using 3 EKGs. Accurate EKG identification was made by 79%. Of these doctors, 31% and 90% in 2 AF and 1 AFL cases, respectively.

Primary Health Care Significance

A 2-fold drawback exists in Greece. First, the NHS has difficulties in financing all examinations and therapies because of high costs and a lack of human and material resources, particularly in rural areas. Second, patients often struggle to access PHC settings and cardiologists, due to economic reasons, insufficient family support, distance, etc.

In this context, a Holter monitor was used in 11 patients out of the 99 referrals and cardioversion was performed in 39 patients by cardiologists. In our PHC unit, the lack of a continuous EKG monitoring device prevented us from attempting pharmacological rhythm conversion.

The majority of recurrent AF/AFL patients used both rhythm and rate control drugs, often unnecessarily. Approximately three fourths received amiodarone, propafenone, or disopyramide, which are not considered to be the optimal treatment. According to the AFFIRM study,²⁰ these drugs are not effective enough and have many side effects, which may lead to an impaired quality of life and suggest rate control as a preferred therapeutic approach. This reveals an insufficient knowledge of the GPs regarding international literature, clinical trials, and guidelines.

In current clinical practice, chronic prophylaxis with drugs is usually used in case of frequent paroxysms after the removal of precipitating factors such as caffeine.⁷ However, many of our paroxysmal AF/AFL patients continued heavy caffeine consumption. Hughes et al,²¹ seeking a consensus on the harmful effects of caffeine, stated that three fourths of the 697 medical specialists recommended caffeine reduction in patients with anxiety, arrhythmias, esophagitis/hiatal hernia, fibrocystic disease, insomnia, palpitations, and tachycardia. Finally, no differences were found in current smokers among the subtypes of AF/AFL, which suggests the need for implementing smoking cessation programs.

A correlation between GHQ-12 scores and certain arrhythmia subtypes was also noticed, and certain gender differences were revealed. Females seemed to report worse distress, which may be in accordance with other studies suggesting a greater impact of AF on the quality of life of women.²¹

In conclusion, common practice in our health center did not fall within the acceptable range, as therapeutic strategies were often inappropriate. The current situation could be improved if GPs endeavored to enhance their knowledge of cardiology and manage arrhythmias better.

Footnotes

Acknowledgements

The authors wish to thank T. Georgiadou, T. Makris, P. Chatzikosma, and I. Chatzijiannakos for their contributions in this survey.

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

The authors received no financial support for the research and/or authorship of this article.

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Is Appropriate Management of Atrial Fibrillation in Primary Care a Utopia?