AIM‐AF: A Physician Survey in the United States and Europe

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Atrial fibrillation (n=629). Intervention: Antiarrhythmic drug prescribing practices and guideline adherence. Primary outcome: Physician adherence to 2020 ESC and 2014/2019 AHA/ACC/HRS atrial fibrillation treatment guidelines for antiarrhythmic drug selection.

Q: What does this research mean for the field?

Cardiologists and electrophysiologists exhibit high rates of clinical guideline nonadherence when selecting antiarrhythmic medications for atrial fibrillation, often prioritizing efficacy over safety recommendations. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

doi:10.1161/jaha.121.023838

March 4, 2022Journal of the American Heart AssociationOpen Access

AIM‐AF: A Physician Survey in the United States and Europe

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Key result

Survey reveals high guideline nonadherence in prescribing antiarrhythmic drugs for AF, reaching ~93% for amiodarone.

n=629

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Why the study?

Guideline recommendations are the accepted reference for AF rhythm control therapies, but physician treatment practices and adherence to guidelines needed to be understood.

Do clinical cardiologists and electrophysiologists in the United States and Europe adhere to ESC and AHA/ACC/HRS guideline recommendations when selecting and monitoring antiarrhythmic drugs for patients with atrial fibrillation?

Key Points

To assess clinical cardiologists' and electrophysiologists' rhythm control treatment practices and evaluate adherence to clinical practice guidelines in atrial fibrillation.
Online 96-question survey administered to clinical cardiologists and electrophysiologists in the United States and Europe (N=629 completed).
Participants actively treated ≥30 patients with atrial fibrillation receiving drug therapy and managed ablation referrals or procedures every 3 months.
While 54% identified guidelines as the top nonpatient factor guiding treatment decisions, amiodarone was chosen by 60% to 80% of respondents across most comorbidity categories.
Nonadherent drug choices included sotalol in renal impairment (21%), outpatient initiation of dofetilide in the United States (16%), class Ic agents in coronary artery disease (6%), and dronedarone in heart failure with reduced ejection fraction (8%).
Physicians prioritized drug efficacy over safety (48% versus 34%), and rhythm control strategies were selected for asymptomatic (antiarrhythmic drugs, 35%; ablation, 8%) and subclinical atrial fibrillation (antiarrhythmic drugs, 38%; ablation, 13%).

Study Design

Type

Cross-Sectional (n=629)

Multicenter

Yes

Structured PICO

Do clinical cardiologists and electrophysiologists in the United States and Europe adhere to ESC and AHA/ACC/HRS guideline recommendations when selecting and monitoring antiarrhythmic drugs for patients with atrial fibrillation?

P

Population

629 clinical cardiologists and electrophysiologists across the United States and 4 European countries who actively treated at least 30 patients with atrial fibrillation every 3 months and managed ablation referrals.

E

Exposure

Online survey (96 questions) assessing physician treatment practices, attitudes, and adherence to 2020 ESC and 2014/2019 AHA/ACC/HRS guidelines for oral antiarrhythmic drugs (amiodarone, sotalol, flecainide, propafenone, dronedarone, dofetilide) and catheter ablation in AF

C

Comparator

Comparison between United States (n=308) and European (n=321) physician practices, and against 2020 ESC and 2014/2019 AHA/ACC/HRS guideline recommendations

O

Outcome

Proportion of physicians reporting treatment selections and monitoring practices that align with or deviate from (noncompliance, deviation, or potential noncompliance) 2020 ESC and 2014/2019 AHA/ACC/HRS AF guidelines

Limitations

Data were dependent on accurate reporting by respondents and subject to recall bias.
Low survey completion rate (7% in the United States and 16% in Europe) from an online market research panel across only 4 European countries.
Survey did not consider antiarrhythmic drug dosing, which influences safety and efficacy.
Clinical thresholds in the survey differed from guideline thresholds (e.g., renal impairment defined as eGFR <60 mL/min per 1.73 m2 vs CrCl <30 mL/min in guidelines).
Nonadherence rates did not include weighting for the degree of deviation from guidelines or potential clinical outcomes.
Recall and reporting bias inherent to self-reported physician surveys
Low survey completion rate (7% in the United States and 16% in Europe) from a market research panel across only 4 European countries, limiting generalizability
Lack of information on antiarrhythmic drug dosing
Differences between clinical thresholds used in the survey (e.g., eGFR <60 mL/min per 1.73 m2 for renal impairment) and those cited in guidelines (CrCl <30 mL/min)
Nonadherence rates did not weight the severity of deviation or potential patient safety outcomes

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Implication

Despite nearly all surveyed cardiologists and electrophysiologists reporting that they follow AF guidelines, real-world clinical decision-making prioritizes efficacy over safety and frequently deviates from guideline recommendations, potentially placing patients at risk for proarrhythmia and organ toxicity.

Abstract

Background Guideline recommendations are the accepted reference for selection of therapies for rhythm control of atrial fibrillation (AF). This study was designed to understand physicians' treatment practices and adherence to guidelines. Methods and Results The AIM-AF (Antiarrhythmic Medication for Atrial Fibrillation) study was an online survey of clinical cardiologists and electrophysiologists that was conducted in the United States and Europe (N=629). Respondents actively treated ≥30 patients with AF who received drug therapy, and had received or were referred for ablation every 3 months. The survey comprised 96 questions on physician demographics, AF types, and treatment practices. Overall, 54% of respondents considered guidelines to be the most important nonpatient factor influencing treatment choice. Across most queried comorbidities, amiodarone was selected by 60% to 80% of respondents. Other nonadherent usage included sotalol by 21% in patients with renal impairment; dofetilide initiation (16%, United States only) outside of hospital; class Ic agents by 6% in coronary artery disease; and dronedarone by 8% in patients with heart failure with reduced ejection fraction. Additionally, rhythm control strategies were frequently chosen in asymptomatic AF (antiarrhythmic drugs [AADs], 35%; ablation, 8%) and subclinical AF (AADs, 38%; ablation, 13%). Despite guideline algorithms emphasizing safety first, efficacy (48%) was selected as the most important consideration for AAD choice, followed by safety (34%). Conclusions Despite surveyed clinicians recognizing the importance of guidelines, nonadherence was frequently observed. While deviation may be reasonable in selected patients, in general, nonadherence has the potential to compromise patient safety. These findings highlight an underappreciation of the safe use of AADs, emphasizing the need for interventions to support optimal AAD selection.

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Cite This Study

A 2022 study conducted a cross-sectional in Atrial fibrillation (n=629). Antiarrhythmic drug prescribing practices and guideline adherence was evaluated on Physician adherence to 2020 ESC and 2014/2019 AHA/ACC/HRS atrial fibrillation treatment guidelines for antiarrhythmic drug selection.

synapsesocial.com/papers/6a85732511a1f3349d109d8d https://doi.org/10.1161/jaha.121.023838

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AIM‐AF: A Physician Survey in the United States and Europe

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

AIM‐AF: A Physician Survey in the United States and Europe

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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