Relationship between care speciality and atrial fibrillation outcomes in the GARFIELD-AF registry
Authors: Camm C J F , Virdone S , Corbalan R , Jerjes Sanchez Diaz C , Oh S , Eikelboom J , Oto A , Fox K A A , Camm A J , Pieper K S , Goto S , Kakkar A J 
Published: November 2023

Abstract

Background
Atrial fibrillation (AF) is associated with cardio-embolic stroke. It remains unclear whether AF outcomes are related to the care speciality at AF diagnosis.

Purpose
To explore associations between the care speciality at AF diagnosis and the risks of clinical outcomes in newly diagnosed AF patients.

Methods
GARFIELD-AF is an international registry of consecutively recruited newly diagnosed AF patients with ≥1 stroke risk factors. Participants were divided based on the care specialty at AF diagnosis: primary care, cardiology, or other medical specialties (internal medicine, neurology, or geriatrics). The follow-up period was from the date of enrolment, truncated at first event occurrence, death, loss to follow-up, or two years after enrolment, whichever occurred first. Hazard ratios for the associations of care speciality with selected clinical outcomes were estimated using Cox proportional-hazards models adjusted for the confounding factors, which included demographics, AF type, medical history, baseline comorbidities, and treatment information.

Results
The study population comprised 52,011 prospectively enrolled GARFIELD-AF patients with available care speciality and follow-up information. Most participants were diagnosed by a cardiology specialist (n=34,172, 65.7%), and fewer by other medical specialists (n=10,443, 20.1%) or primary care practitioners (n=7,396, 14.2%). Patients diagnosed by cardiologists were on average younger, had lower BMI, and were more likely to have paroxysmal AF when first diagnosed. These patients also received NOAC more frequently (30.1%), compared to patients diagnosed by other medical specialties (24.2%) or primary care practitioners (20.4%, Table 1). CHA2DS2-VASc and HAS-BLED scores were similar across care specialities. The proportion of patients treated by a cardiologist differed substantially between countries, ranging from 9% in Finland to 97% in Egypt.
Patients cared for by non-cardiology medical specialties had a greater risk of all-cause mortality (HR 1.23, 95%CI 1.08 to 1.39), non-cardiovascular mortality (HR 1.31, 1.12 to 1.53) and non-haemorrhagic stroke/systemic embolism (HR 1.45, 1.18 to 1.80) compared with participants cared for by a cardiologist. Patients treated by primary care practitioners had a lower all-cause mortality risk compared with those diagnosed by cardiologists (HR 0.86, 0.74 to 0.99) (Figure 1).

Conclusions
Overall, patients developing new AF were most often diagnosed by cardiologists, but substantial regional variation existed. Patients diagnosed by cardiologists received NOACs more frequently compared to patients diagnosed from other care specialties. Patients treated by non-cardiology medical specialities experienced a comparatively greater risk of death and non-haemorrhagic stroke. Cardiology expertise could have important implications for the care of newly diagnosed AF patients.Figure 1Table 1