Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF

Alan John Camm; Jan Steffel; Saverio Virdone; Jean-Pierre Bassand; Keith A A Fox; Samuel Z Goldhaber; Shinya Goto; Sylvia Haas; Alexander G G Turpie; Freek W A Verheugt; Frank Misselwitz; Ramón Corbalán Herreros; Gloria Kayani; Karen S Pieper; Ajay K Kakkar; GARFIELD-AF Investigators

doi:10.1093/ehjopen/oead051

Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF

Eur Heart J Open. 2023 May 19;3(3):oead051. doi: 10.1093/ehjopen/oead051. eCollection 2023 May.

Authors

Alan John Camm¹, Jan Steffel², Saverio Virdone³, Jean-Pierre Bassand^{3

4}, Keith A A Fox⁵, Samuel Z Goldhaber⁶, Shinya Goto⁷, Sylvia Haas⁸, Alexander G G Turpie⁹, Freek W A Verheugt¹⁰, Frank Misselwitz¹¹, Ramón Corbalán Herreros¹², Gloria Kayani³, Karen S Pieper³, Ajay K Kakkar³; GARFIELD-AF Investigators

Affiliations

¹ Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK.
² University of Zurich, Zurich, Switzerland.
³ Thrombosis Research Institute, London, UK.
⁴ University of Besançon, Besançon, France.
⁵ Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
⁶ Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
⁷ Tokai University, Kanagawa, Japan.
⁸ Formerly Department of Medicine, Technical University of Munich, Munich, Germany.
⁹ McMaster University, Hamilton, Canada.
¹⁰ Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands.
¹¹ Actimed Therapeutics, Berkshire, UK.
¹² Pontificia Universidad Católica de Chile, Santiago, Chile.

Abstract

Aims: This study aimed to identify relationships in recently diagnosed atrial fibrillation (AF) patients with respect to anticoagulation status, use of guideline-directed medical therapy (GDMT) for comorbid cardiovascular conditions (co-GDMT), and clinical outcomes. The Global Anticoagulant Registry in the FIELD (GARFIELD)-AF is a prospective, international registry of patients with recently diagnosed non-valvular AF at risk of stroke (NCT01090362).

Methods and results: Guideline-directed medical therapy was defined according to the European Society of Cardiology guidelines. This study explored co-GDMT use in patients enrolled in GARFIELD-AF (March 2013-August 2016) with CHA₂DS₂-VASc ≥ 2 (excluding sex) and ≥1 of five comorbidities-coronary artery disease, diabetes mellitus, heart failure, hypertension, and peripheral vascular disease (n = 23 165). Association between co-GDMT and outcome events was evaluated with Cox proportional hazards models, with stratification by all possible combinations of the five comorbidities. Most patients (73.8%) received oral anticoagulants (OACs) as recommended; 15.0% received no recommended co-GDMT, 40.4% received some, and 44.5% received all co-GDMT. At 2 years, comprehensive co-GDMT was associated with a lower risk of all-cause mortality [hazard ratio (HR) 0.89 (0.81-0.99)] and non-cardiovascular mortality [HR 0.85 (0.73-0.99)] compared with inadequate/no GDMT, but cardiovascular mortality was not significantly reduced. Treatment with OACs was beneficial for all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use; only in patients receiving all co-GDMT was OAC associated with a lower risk of non-haemorrhagic stroke/systemic embolism.

Conclusion: In this large prospective, international registry on AF, comprehensive co-GDMT was associated with a lower risk of mortality in patients with AF and CHA₂DS₂-VASc ≥ 2 (excluding sex); OAC therapy was associated with reduced all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use.

Clinical trial registration: Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.

Keywords: Atrial fibrillation; Comorbidity; GARFIELD-AF; Guideline-directed medical therapy; Mortality; Oral anticoagulant.

Associated data

ClinicalTrials.gov/NCT01090362