This website is intended for healthcare professionals only.
Take a look at a selection of our recent media coverage:
6th February 2025
Switching from beta-blockers to digoxin as first line therapy for heart rate control in older patients with atrial fibrillation (AF) and symptoms of heart failure could produce a cost saving of over £100m a year for the NHS, a study has found.
AF accounted for more than 1% of the annual NHS budget, predominantly from hospital admissions, researchers wrote in the journal Heart.
The RAte control Therapy Evaluation in permanent Atrial Fibrillation (RATE-AF) study was a randomised, open-label trial embedded in the NHS that directly compared low-dose digoxin – usually used as second-line therapy – with the typical first-line approach of beta-blockers.
The trial initially randomised 160 older patients with permanent AF and symptoms of heart failure (mean age 76 years, 46% women).
Researchers previously reported no difference in the primary outcome of health-related quality of life in the physical activity domain between the groups at six months, however nearly all secondary outcomes favoured digoxin by 12 months, with better patient functional capacity and less evidence of cardiac strain.
There were lower rates of side effects, cardiovascular events and hospital admissions in those randomised to digoxin.
For this prespecified health economic analysis of the National Institute for Health and Care Research-funded trial, researchers assessed information from the 149 patients who had complete data and survived to 12 months follow-up.
The analysis found no significant effect on quality-adjusted life years (QALY) between groups, however treatment with digoxin was significantly less costly than therapy with beta-blockers, with a mean saving of £530.41 per patient per year.
‘This was principally due to substantially lower rates of adverse events, with less primary and secondary healthcare utilisation compared with beta-blocker therapy,’ the researchers reported.
Extrapolating the study findings to current prevalence and costs of AF in the NHS, suggested a potential cost saving of £102 million per year, which was equivalent to a 5.9% saving on the £1.7bn spent annually on AF, the study reported.
The researchers noted the cost of secondary care services, mainly inpatient care, was significantly lower in the digoxin arm, reflecting that these patients had substantially fewer serious adverse events (16 serious adverse events in 13 patients for digoxin vs 37 in 21 patients for beta-blockers) and fewer treatment-related adverse events (29 treatment-related adverse events in 20 patients for digoxin vs 142 in 51 patients for beta-blockers).
The mean total costs for secondary care were £8.88 per patient over 12 months in the digoxin group and £484.83 per patient in the beta-blocker group, with adjusted bootstrapped difference of –£518.04 per patient in favour of digoxin.
‘While likely applicable to similar healthcare settings outside the UK, further studies with formal economic evaluation are needed to address this key evidence gap and the implications for global management of patients with AF,’ the authors concluded.
Corresponding author Professor Sue Jowett, deputy head of the Health Economics Unit at the University of Birmingham, said the study highlighted the importance of health economic assessments and the role they could play in delivering appropriate treatments.
‘At the usual £20,000 per QALY threshold, the probability of digoxin being cost-effective compared to beta-blockers was 94%, which could lead to substantial savings if the trial results were adopted more broadly in this population,’ she said.
Trial chief investigator Professor Dipak Kotecha, professor of cardiology at the University of Birmingham, and a consultant cardiologist specialising in cardiac imaging at University Hospitals Birmingham NHS Trust, said cardiac conditions such as AF and heart failure were expected to double in prevalence over the next few decades.
‘Despite being one of the oldest drugs in use for heart disease, this study confirms an important role for digoxin in the management of these patients, providing safe and cost-effective treatment,’ he said.
Last year, the European Society of Cardiology released new guidelines at its congress in London, including one dedicated to the management of AF.
The novelties of this AF guideline included the recommendation of the new CHA2DS2-VA score to assess thromboembolic risk when making decisions on initiating oral anticoagulation, which no longer includes gender.
21st October 2024
Education programmes for healthcare professionals involved in the management of atrial fibrillation can increase adherence to guidelines and improve patient safety, according to a recent trial.
Researchers found that current adherence to treatment guidelines for atrial fibrillation is low across six European countries. They concluded that increased efforts are needed to improve the implementation of guidelines and to optimise the care of patients with atrial fibrillation to prevent the high rate of adverse outcomes.
The STEER-AF trial involved 739 healthcare professionals and 1,732 patients with atrial fibrillation in 70 treatment centres across France, Germany, Italy, Poland, Spain and the UK between May 2022 and February 2023. The average age of participants was 69 years, and 37% were female.
Researchers randomly assigned treatment centres to one of two groups to determine whether a structured educational programme could improve adherence to guideline recommendations and the care of patients with atrial fibrillation.
In the intervention group, a total of 195 healthcare professionals received a structured education programme delivered over 16 weeks, targeting stroke prevention, rhythm control and integrated care. Healthcare professionals spent an average of 9.2 hours on the online learning platform and expert local trainers provided learning support. This was in addition to any existing continued professional development.
In the control group, healthcare professionals received only their existing educational activities.
The researchers tracked how well healthcare professionals followed the European Society of Cardiology (ESC) guidelines, in particular adherence to ESC Class I (strongly recommended treatments) and Class III recommendations (treatments that are not recommended) at baseline and six to nine months later.
The study observed a significant improvement in guideline adherence for rhythm control, with adherence increasing from 21.4% to 33.9% in the intervention group and from 20.5% to 22.9% in the control group.
There was no significant improvement in guideline adherence for stroke prevention, which changed from 63.4% to 67.5% in the intervention group and from 58.6% to 60.9% in the control group.
There was also a significant improvement in the patient-reported secondary outcome that assessed eight domains of integrated atrial fibrillation management, improving to 77.0% with the intervention and to 71.0% in the control group. All results were statistically significant and had a reliable confidence level.
The findings of this study are incorporated into the 2024 ESC Guidelines for atrial fibrillation management, which were presented at the ESC Congress 2024.
Reference
Sterliński, M et al. Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association. EP Europace 2024; Jun 28: DOI: 10.1093/europace/euae178.
19th September 2024
Gender should not play a role in decision-making for oral anticoagulation in patients with atrial fibrillation, a new study concludes.
The research, published in the European Heart Journal, indicates that removing gender from clinical risk scores could simplify the process of deciding which patients should be given blood thinning medication without compromising on accuracy.
Streamlining the risk stratification process would also contribute to equality in care, according to the study’s authors.
The researchers say the findings contribute to growing evidence to avoid consideration of the patient’s gender when offering this type of medication in atrial fibrillation management.
The findings are in line with the new 2024 European Society of Cardiology (ESC) guidelines, which were presented this month at the ESC Congress in London.
Historical data has reported higher rates of strokes in women with atrial fibrillation, but this is likely associated with other risk factors, such as older age at the time of the stroke and lower anticoagulation rates in women, and higher mortality rates in men.
More recently, gender has been considered a risk modifier. However, international guidelines vary considerably.
To understand whether female gender should play a role in the decision-making process for the prescription of anticoagulants, researchers from the University of Birmingham conducted a large observational study.
The analysis involved 78,852 patients with atrial fibrillation, 28,590 of whom were female.
All patients over the age of 75 and those with a history of a prior stroke were excluded since the use of anticoagulants is standard clinical practice in these groups, regardless of gender.
The research cohort focused on a group of patients where the need for anticoagulation medication was less clear.
Differences between men and women, including age and other health conditions were accounted for.
Using UK primary care electronic health records, the analysis showed women with atrial fibrillation had a lower a rate of death from any cause, stroke or major blood clot, combined, than men. This was mainly due to lower mortality among the women. Rates of stroke, arterial blood clots and vascular dementia did not differ between women and men during the average of five years of follow-up.
The team then examined the effectiveness of the most commonly used global stroke risk assessment tool, the CHA2DS2-VASc score, which is recommended by NICE.
The findings showed that the tool only modestly predicted which patients would go on to have an adverse outcome, like stroke, and when used without gender input (CHA2DS2-VA) the tool had slightly better precision.
Dr Asgher Champsi, clinical research fellow at the University of Birmingham and co-first author of the paper, said: ‘This research questions whether gender should be used to make decisions on the prevention of stroke, blood clots and death in patients with atrial fibrillation.
‘Removing gender from clinical risk scores could streamline risk stratification without compromising accuracy, and contribute to equality in care.’
Dipak Kotecha, Professor of cardiology at the University of Birmingham, added: ‘Healthcare professionals and patients need to be aware of the poor performance of available risk scores.
‘A personalised approach to decision-making on oral anticoagulation is critical to improve outcomes for patients with atrial fibrillation and reduce the huge burden of health and social care costs.
‘Rather than gender, this includes a broader range of factors that can lead to blood clots beyond conventional risk scores.’
A version of this article was originally published by our sister publication Nursing in Practice.
6th June 2024
A new study has demonstrated a ‘clear correlation’ between atrial fibrillation and vascular dementia, as well as a much higher risk of developing stroke or a major blood clot than those without the heart condition.
Researchers at the University of Birmingham found that individuals with atrial fibrillation, who were considered low-risk patients, had a 68% higher chance of developing vascular dementia than patients without the heart condition. There was however no correlation with the development of Alzheimer’s disease.
The research also found that the low-risk patients had double the chance of developing a stroke or major blood clot than those without atrial fibrillation and suggest that a thromboembolic mechanism is contributing to the development of vascular dementia in patients with atrial fibrillation.
This adds to existing evidence that the heart condition is associated with strokes and blood clots in older patients and those with other health conditions.
The findings, published in the journal Nature Medicine, highlight an additional consequence of this common heart condition, which the researchers advise clinicians to be aware of and attempt to prevent, particularly amongst younger, lower risk patients.
Patients with atrial fibrillation are typically given anticoagulants as stroke prevention therapy but younger patients and those otherwise perceived as ‘low-risk’ are not prescribed the blood thinning medication.
The study was a UK population-based analysis using electronic healthcare records from 5,199,994 primary care patients collected between 2005 and 2020. Just over 5% (290,525) of the patients analysed, who were all between the ages of 40 and 75, had a diagnosis of atrial fibrillation.
The researchers focused on 36,340 of these patients who were not receiving anticoagulation therapy and were considered low-risk based on a standard risk score (CHA2DS2-VASc score <2). The team compared these patients’ outcomes with those of 117,298 control patients without atrial fibrillation, who were matched for age, sex and region.
Rates of death and thromboembolic outcomes, including vascular dementia, during the study were substantially increased in the patients with atrial fibrillation despite their low-risk status.
In the five-year follow up period, 3.8% of patients with atrial fibrillation had a stroke compared with 1.5% of those without the heart condition. Meanwhile, 5.6% versus 2.7% developed ischaemic heart disease, respectively. All-cause mortality was also increased in those with atrial fibrillation, at 8.9% versus 5% for those without.
Adjusting for various potential contributing factors, the authors found atrial fibrillation was associated with a two-fold increased risk of stroke and 1.9-fold increased risk of ischaemic heart disease.
Atrial fibrillation was also associated with an increased rate of all-cause dementia (1.2% versus 0.7% in those without). The report this was driven by vascular dementia cases (0.4% versus 0.1%, respectively), and that those with atrial fibrillation had a 1.68-fold increased risk of developing vascular dementia compared to those without after adjusting for other factors.
Alastair Mobley, a PhD researcher at the University of Birmingham and first author of the study, said: ‘This study demonstrates a clear correlation between AF and vascular dementia. This may have a similar mechanism to the association between AF and stroke.’
The prevention of thromboembolism in atrial fibrillation is typically restricted to older patients or those with specific risk factors and currently does not consider outcomes such as vascular dementia. Ongoing clinical trials such as DaRe2THINK are exploring whether anticoagulants in lower-risk patients can provide a way to prevent the increased risk of thromboembolic outcomes, including vascular dementia.
Dipak Kotecha, professor of cardiology at the University of Birmingham and senior author of the study, added: ‘Atrial fibrillation is one of the most common heart conditions. With its prevalence continuing to rise, it is crucial that we develop strategies to prevent not only stroke but outcomes like dementia, which are a big concern for patients and healthcare systems. Our research highlights the urgency of addressing AF comprehensively, considering its overall impact on the wellbeing of patients.’
A version of this article was originally published by our sister publication Nursing in Practice.
16th April 2024
Treating atrial fibrillation with catheter or surgical ablation is the subject of a new international consensus statement presented at the recent European Heart Rhythm Association (EHRA) Congress 2024.
Also published in the journal EP Europace, among others, the consensus statement sets out best practice standards and defines a contemporary framework for the selection and preprocedural, procedural and postprocedural management of patients considered for, or undergoing, catheter or surgical atrial fibrillation ablation.
It outlines atrial fibrillation pathophysiology, anatomical considerations, evaluation and management of complications, training, and institutional requirements for atrial fibrillation ablation.
And it also highlights the importance of active and healthy lifestyles in reducing the risk of developing atrial fibrillation and to lower the number of recurrences.
The consensus statement was developed by the EHRA, a branch of the European Society of Cardiology which chaired the process; the Heart Rhythm Society; the Asia Pacific Heart Rhythm Society; and the Latin American Heart Rhythm Society.
Lead author Dr Stylianos Tzeis, head of cardiology clinic and electrophysiology and pacing department at the Mitera Hospital in Athens, Greece, noted that technological innovations have made catheter ablation safer and more effective than ever before, with pulsed field ablation and intracardiac echocardiography revolutionising the procedure.
He said: ‘Ablation is the most effective way to prevent recurrences of atrial fibrillation and delay progression to more advanced forms. Pioneering techniques have emerged since the previous consensus in 2017, requiring new advice on who should receive this procedure and how to perform it in the safest and most effective manner.’
The consensus statement emphasises that it ‘is not intended as a guideline’ but ‘aims to document the current expert consensus in the dedicated narrow field of catheter and surgical AF ablation’.
It adds: ‘Healthcare professionals should refer to the latest guidelines for overall structured management of [atrial fibrillation] patients.’
15th April 2024
Any level of passive smoking universally elevates the risk of atrial fibrillation, according to new research presented at the recent European Heart Rhythm Association Congress 2024.
The researchers examined the association between secondhand smoke exposure and the long-term risk of incident atrial fibrillation, aiming to add to existing research that has established links between passive smoking and coronary artery disease and premature death.
They found a dose-dependent relationship between passive smoking duration and atrial fibrillation risk, with each increase in the duration of weekly passive smoking linked with an even greater risk of atrial fibrillation.
The study included 400,493 adults aged 40-69 years (55.2% women) who had used the NHS for any reason and were enrolled in the UK Biobank. Current smokers and those with atrial fibrillation at baseline were excluded from the study.
A touchscreen questionnaire was used to ask participants the number of hours they had been exposed to other people’s smoke in a typical week over the past year at home and in other environments.
Participants were then categorised into the ‘exposed group’ if they had any contact with secondhand smoke and the ‘non-exposed group’ if they had no contact with secondhand smoke.
Some 85,984 (21%) participants had been exposed to secondhand smoke in the previous year, with an average exposure of 2.2 hours per week. During a median follow-up of 12.5 years, atrial fibrillation developed in 23,471 (6%) participants.
After adjusting for factors that could potentially affect the relationship, the group exposed to secondhand smoke had a 6% higher risk of incident atrial fibrillation during follow-up compared with the non-exposed group (hazard ratio 1.06, 95% confidence interval 1.03–1.10, p <0.001).
A dose-dependent relationship was observed, with 7.8 hours of passive smoking per week associated with an 11% higher likelihood of the heart rhythm disorder compared with no passive smoking.
The risk of atrial fibrillation for passive smokers was found to be raised in homes and workplaces as well as in outside spaces.
‘According to our study, once exposed to secondhand smoke, the likelihood of developing atrial fibrillation begins to increase, with the risk escalating significantly as the exposure time lengthens,’ said study author Dr Kyung-Yeon Lee of Seoul National University Hospital, Seoul, Republic of Korea.
‘The dangers of secondhand smoke were significant regardless of whether individuals were at home, outdoors or at work, indicating that exposure universally elevates the risk of atrial fibrillation.’
The authors said the results highlight the importance of smoking bans to protect public health and Dr Lee added that everyone should ‘make every effort to avoid spending time in smoky environments’.
He also urged policymakers to take note and ‘further curb smoking in public areas and support smoking cessation programmes to improve public health’.
In March 2023, the Federation of the Royal Colleges of Physicians in the UK warned of ‘significant and avoidable’ demand on NHS due to socio-economic inequalities, which included the impact of smoking.
Last year, questions were raised over whether the risk of atrial fibrillation increased with fish oil supplementation.
4th September 2023
Individuals with a greater exercise capacity have a reduced risk of developing atrial fibrillation (AFib), ischaemic stroke and major adverse cardiovascular events (MACE), according to the findings of a large study presented at the European Society of Cardiology (ESC) Congress, 2023.
AFib is the most common cardiac arrhythmia and has a number of different causes including auto-immune diseases such as rheumatoid arthritis.
Whether being physically fit might reduce the risk of developing AFib is unclear, although some evidence reveals a graded, inverse relationship between cardiorespiratory fitness and incident AFib, especially among obese individuals.
The study included 15,450 individuals without AFib who had a mean age of 54.9 years (59% male). All participants were referred for a treadmill test between 2003 and 2012.
Fitness was assessed using the Bruce protocol, where participants are asked to walk faster and at a steeper grade in successive three-minute stages. It was then calculated according to the rate of energy expenditure the participants achieved, which was expressed in metabolic equivalents (METs).
Participants were then divided into three fitness levels according to the METs achieved during the treadmill test: low (less than 8.57 METs), medium (8.57 to 10.72) and high (more than 10.72).
The researchers looked for independent associations between exercise capacity on the treadmill and the risk of new-onset AFib, risk of ischaemic stroke and MACE. The results were adjusted for potential confounders including age, sex, cholesterol level, kidney function, prior stroke, hypertension and any medications.
During the period of follow-up, new-onset AFib occurred in 3.33% of participants.
In fully adjusted models, each one MET increase in exercise treadmill testing, there was an associated 8% lower risk of AFib incidence (hazard ratio, HR = 0.92, 95% CI 0.88 – 0.97).
In addition, this one MET increase was also associated with a lower risk of ischaemic stroke (HR = 0.88, 95% CI 0.83 – 0.94) and a 14% reduced risk of MACE (HR = 0.86, 95% CI 0.84 – 0.88).
In fact, the probability of remaining free from AFib over a five-year period was calculated to be 97.1%, 98.4% and 98.4% in the low, medium and high exercise capacity groups, respectively.
Study author Dr Shih-Hsien Sung of the National Yang Ming Chiao Tung University in Taipei, Taiwan, said: ‘This was a large study with an objective measurement of fitness and more than 11 years of follow up. The findings indicate that keeping fit may help prevent atrial fibrillation and stroke.‘
25th July 2023
Researchers have identified that a particular gene highly over-expressed in macrophages during atrial fibrillation (AFib) could serve as a future therapeutic target.
AFib leads to disrupted contraction of the atria, increasing the risk of both a stroke and heart failure. Now, a research study led by investigators at Massachusetts General Hospital (MGH) and published in the journal Science, shows that macrophage immune cells appear to have an important role in the development of AFib.
Their study was able to decipher how immune and stromal cells contribute to the arrhythmia. The team compared atrial tissue from patients with and without AFib and developed a mouse model of AFib which integrated hypertension, obesity and mitral valve regurgitation (HOMER) in which these cellular and transcriptomic changes were recapitulated.
Using single-cell transcriptomes from human atria, researchers found inflammatory monocyte and SPP1+ macrophage expansion in atrial fibrillation. In addition, gene expression analyses showed that, in both human and mouse hearts, the SPP1 gene is highly over-expressed in macrophages during AFib. The gene produces a protein called SPP1 protein which promotes tissue scarring and is elevated in the blood of patients with AFib. In contrast, in the HOMER mice model, there were a reduced numbers of atrial macrophages when SPP1 was absent.
Through the use of cell-cell interaction analysis, it was revealed how SPP1 provided a pleiotropic signal that promoted atrial fibrillation through cross-talk with local immune and stromal cells. Moreover, the deletion of SPP1 in HOMER mice reduced AFib, which suggests that SPP1+ macrophages could serve as a target for immunotherapy in patients with atrial fibrillation.
Commenting on the research, senior author Matthias Nahrendorf from Massachusetts General Hospital, said: ‘We found that recruited macrophages support inflammation and fibrosis, or scarring, of the atria, which hinder electrical conduction between heart cells and lead to AFib. Inhibiting macrophage recruitment reduced AFib.
‘We think that this research lays the groundwork for immunomodulatory therapy of AFib, and we are currently working on several strategies to make this happen.‘
1st June 2023
SGLT-2 inhibitor use in people with both diabetes and atrial fibrillation reduces the risk of ischaemic strokes, according to the results of a longitudinal follow‐up study.
Atrial fibrillation (AF) is the most common global cardiac arrhythmia, affecting over three million people. Having AF increases the risk of ischaemic stroke with this risk stratified by the CHA2DS2-VASc score. Fasting hyperglycaemia is a risk factor for AF although the use of sodium-glucose cotransporter-2 (SGLT-2) inhibitors reduces this risk.
The researchers considered whether SGLT-2 inhibitors could therefore reduce the risk of ischaemic stroke in diabetics with AF. Published in the Journal of the American Heart Association, the Taiwanese study followed a group of patients with both diabetes and AF who were prescribed either empagliflozin or dapagliflozin. These individuals were propensity matched to non-users and the incidence of ischaemic strokes documented over the next five years.
A total of 6,614 patients, 801 prescribed one of the SGLT-2 inhibitors, had usable data for analysis.
After five years, 809 patients with diabetes and AF developed an ischaemic stroke. However, the rate was significantly lower among SGLT-2 inhibitor users (p = 0.021).
As expected, there was an increased risk of stroke per one-point increase CHA2DS2‐VASc score (hazard ratio, HR = 1.24, 95% CI 1.20 – 1.29, p < 0.001). Adjusting for the CHA2DS2‐VASc score lowered the stroke risk by 20% among SGLT-2 inhibitor users (HR= 0.80, 95% CI 0.64 – 0.99, p = 0.043).
The findings prompted the authors to suggest clinicians upgrade SGLT-2 inhibitors for glycaemic control, especially in those with co-existing AF.
26th April 2023
The risk of different types of strokes is significantly lower in patients with atrial fibrillation who use who use one of the statin drugs.
Atrial fibrillation (AF) represents the most frequent cardiac arrhythmia. Data from 2017 suggests that globally, the condition affects 3.046 million people. Moreover, AF leads to a five-fold increase in stroke risk with up to 30% of these due to the arrhythmia.
In data presented at EHRA 2023, the risk of strokes was lower in AF patients using statins within a year of their diagnosis. While it is already known that statin use in AF reduces the risk of all-cause mortality. But whether the drugs reduce stroke risk is uncertain.
However, some data suggests that high intensity statins may reduce cerebral events in patients with acute ischaemic stroke and AF.
In the study at EHRA 2023, researchers from Hong Kong, examined a cohort of newly diagnosed AF patients. Individuals were either statin or non-statin users in relation to their AF diagnosis. For instance, a statin user was taking the drug before their AF diagnosis.
The primary outcome was any form of stroke, e.g., ischaemic, systemic embolism, haemorrhagic or a transient ischaemic attack (TIA).
A total of 51,472 AF patients of whom, 11,866 were receiving a statin had analysable data.
During a median follow-up of 5.1 years, among statin users, the ischaemic stroke and systemic embolism risk was 17% lower than non-users (Hazard ratio, HR = 083, 95% CI 0.78 – 0.89). The risk of a haemorrhagic stroke (HS) was 7% lower (HR = 0.93) and the TIA risk 15% lower (HR = 0.85).
Use of statins for 6 years would reduce the risk of an ischaemic stroke or system embolism by 43% compared to use for less than 2 years (HR = 0.57). This risk was also lower for the other cerebral events.
IMPORTANT LINKS
MORE FROM COGORA
© Cogora 2025
Cogora Limited. 1 Giltspur Street, London EC1A 9DD
Registered in the United Kingdom. Reg. No. 2147432
