Study Looks at Global Mortality, Stroke Rates in A-fib Patients After ER Visit

MUNICH, Germany—Globally, a tenth of patients presenting to an emergency department with atrial fibrillation (A-fib) will die within 1 year, according to registry data presented on August 29, 2012, at the European Society of Cardiology Congress. However, this rate is highly variable by geographic region.

For RE-LY AF, Jeff S. Healey, MD, MSc, of McMaster University (Hamilton, Canada), and colleagues looked at 15,408 A-fib patients who visited emergency departments from January 2008 to April 2011 in 47 countries.

Vast Regional Variability

Overall mortality at 1 year was 11% and ranged from about 9% in Europe and India to about 20% in Africa. When mortality was adjusted for patient characteristics, the varying rates became closer to the global average in all regions.

Worldwide, patients with A-fib as their primary diagnosis had a mortality rate of just over 5% and better outcomes than those who came in for other reasons. In Africa, the mortality rate for patients with A-fib as their main diagnosis neared 12%, while in Southeast Asia the rate was about 3%.

The overall stroke rate was 4%; rates ranged from 2% to 3% in the Americas, Western Europe, and India to as much as 6% to 8% in Africa, China, and Southeast Asia.

The top cause of death in the registry was heart failure (34%), followed by infection (13%) and stroke (10%). MI was the cause of death in only 5% of patients. In North America, heart failure was the cause of death in 1 in 5 patients, while in Africa, heart failure was the cause of death in nearly half of the patients. Rates of stroke as the cause of death varied substantially as well, with very few patients in Western Europe and as much as 20% of patients in Africa dying of stroke.

Average patient age was just over 70 years for all but those in the Middle East, Africa, and India, where the average age was slightly more than 60 years. Patients with rheumatic heart disease (n = 1,788) tended to be much younger (average 49.5 years), were more likely to be female, and had a very low prevalence of coronary disease.

A Global Problem

Globally, the mortality rate was “higher than we expected,” Dr. Healey said. While the variability of this rate among countries can be attributed to demographic characteristics and risk factors, there may have also been unmeasured bias in patient selection, he suggested.

Commenting on the data, Gregory Y. H. Lip, MD, of City Hospital (Birmingham, United Kingdom), said the study provides “excellent data on the global impact of [A-fib].” The condition “is not confined to North America and Europe,” he said, noting that “high-quality registries are clearly required to improve the understanding of the worldwide burden of atrial fibrillation.”

In terms of the varying global stroke rates, Dr. Lip said it would be worthwhile “look at the quality of anticoagulation care and, even more, the access to anticoagulation monitoring.”

As for clinical implications, “there is a clear unmet need for improving stroke prevention in patients with atrial fibrillation globally,” Dr. Lip concluded, adding that it will be necessary to “validate and implement stroke and bleeding risk assessment” going forward.


Healey J. RE-LY AF: Global variations in the 1-year rates of death and stroke in 15,432 patients presenting to the emergency department with atrial fibrillation in 47 countries: The RE-LY AF Registry. Presented at: European Society of Cardiology Congress; August 29, 2012; Munich, Germany.



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  • Dr. Healey reports receiving grant support from and serving as a consultant to multiple pharmaceutical companies.
  • Dr. Lip reports serving as a consultant and speaker for multiple pharmaceutical and device companies.