Regional differences in presentation and treatment of patients with atrial fibrillation in Europe: a report from the EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry

Lip, Gregory Y.H.; Laroche, Cécile; Boriani, Giuseppe; Dan, Gheorghe-Andrei; Santini, Massimo; Kalarus, Zbigniew; Rasmussen, Lars Hvilsted; Oliveira, Mário Martins; Mairesse, Georges; Crijns, Harry J.G.M.; Simantirakis, Emmanouil; Atar, Dan; Maggioni, Aldo P.; Tavazzi, Luigi

doi:10.1093/europace/euu201

Aims

Country differences in management practices are evident, and the publication of management guidelines by the European Society of Cardiology (ESC) and other learned societies has tried to recommend a uniform evidence-based approach to management. Despite the availability of guidelines and efforts to improve implementation, differences in guideline adherence are evident, and differences between countries and regions within Europe are therefore likely.

Methods and results

In this analysis from the baseline dataset of the EORP-AF Pilot survey, we examined regional differences in presentation and treatment of contemporary patients with atrial fibrillation (AF) in Europe, as managed by European cardiologists. We focused on a subgroup of 902 hospital admitted patients in whom no rhythm control was performed or planned. Chronic heart failure was more common in East countries (P < 0.0001) while hypertension and peripheral artery disease were more common in South countries (both P < 0.0001). Previous bleeding and chronic kidney disease were more common in South countries (both P < 0.0001). A CHA₂DS₂-VASc score of ≥2 was highest in East and South countries (93.0 and 95.3%, respectively) compared with 80.8% in West countries (P < 0.0001). A HAS-BLED score of ≥3 was also highest in East and South countries (18.0 and 29.2% respectively) compared with 4.8% in West countries (P < 0.0001). Oral anticoagulation (OAC) use (either as OAC or OAC plus antiplatelet therapy) in West, East, and South countries was 72.0, 74.7, and 76.2%, respectively. Only antiplatelet therapy was used in 13.6, 15.4, and 12.4%, respectively. An initial rate control strategy only was most common in South countries (77.8%) (P < 0.0001).

Conclusion

From the systematic collection of contemporary data regarding the management and treatment of AF in nine participating member ESC countries, we provide hypothesis-generating insights into regional management practices in Europe with regard to patient characteristics and treatment options.

Atrial fibrillation, Geographical differences, Guidelines

What's new?

We provide systematic collection of contemporary data regarding the management and treatment of AF in nine participating member ESC countries.
There are important hypothesis-generating insights into regional management practices in Europe with regard to patient characteristics and treatment options.

Introduction

Atrial fibrillation (AF) remains the commonest sustained cardiac arrhythmia worldwide, and given the complications associated with this increasingly prevalent arrhythmia, AF confers a major public health burden. Recent projections based on the Rotterdam study suggest that from 2010 to 2060, the number of adults ≥55 years with AF in European countries will increase 2-fold, to 17.9 million (95% CI: 13.6–23.7 million) assuming that the age- and sex-specific prevalence remains stable.¹ Similar observations have been noted in North America.²

The European Society of Cardiology (ESC) conducted the EuroHeart survey a decade ago, to get an insight into the epidemiology and clinical practice of European cardiologists, related to AF.³ Since that initial survey, many new studies have addressed the impact of rate vs. rhythm control, and the use of catheter ablation—which have shaped new guidelines.^4,5 Furthermore, the contemporary management of AF has changed towards being more patient-centred and symptom-directed.⁶

Country differences in management practices are evident, and the publication of management guidelines by the ESC and other learned societies has tried to recommend a uniform evidence-based approach to management. Indeed, the guideline adherent treatment of AF is associated with much better outcomes.^7,8 Despite the availability of guidelines and efforts to improve implementation, differences in guideline adherence are evident in everyday practice.^9–11 Differences between countries and regions within Europe are therefore likely.

In this analysis from the baseline dataset of the EORP-AF Pilot survey, we examined regional differences in presentation and treatment of contemporary patients with AF in Europe, as managed by European cardiologists.

Methods

The full baseline features and results from the EORP-AF Pilot survey have been previously published.¹⁰ In this ancillary analysis, we focused on regional differences in clinical features and management. In brief, the EORP-AF registry population comprised consecutive in- and out-patients with AF presenting to cardiologists in participating ESC countries. For the whole registry, consecutive patients were screened for eligibility at the time of their presentation to a cardiologist (either based at hospital or non-hospital medical outpatient centre). All patients provided written informed consent. Patients with the primary or secondary recorded diagnosis of AF were included.

As previously described, patients were officially enrolled in the EORP-AF only if an electrocardiogram (ECG) diagnosis (12-lead ECG, 24 h Holter, or other electrocardiographic documentation) confirming AF was made.¹⁰ The qualifying episode of AF should have occurred within the last year, and patients did not need to be in AF at the time of enrolment. For the pilot phase, nine countries formally participated. A minimum of 20 consecutive patients per centre were to be enrolled, with a target of 3000 patients. Enrolment into the registry started in February 2012, and the end of enrolment was March 2013.

As only nine countries participated in the EORP-AF Pilot General registry, we arbitrarily divided the participating countries into three country groups: West (Belgium, Denmark, Netherlands, and Norway), East (Poland and Romania), and South (Greece, Italy, and Portugal). We recognize the artificial nature of such a division, but modest patient numbers in some individual countries preclude meaningful country-by-country comparisons.

Statistical analyses

Univariate analysis was applied to both continuous and categorical variables. Continuous variables were reported as mean ± SD or as median and interquartile range (IQR). Among-group comparisons were made using a non-parametric test (Kruskal–Wallis test). Categorical variables were reported as percentages. Among-group comparisons were made using a χ² test or Fisher's Exact test if any expected cell count was less than five.

Results

The EORP-AF Pilot registry enrolled 3119 patients overall, from nine countries and detailed baseline data have previously been reported for the whole cohort.¹⁰ Table 1 summarizes patient characteristics and antithrombotic drug use among the subgroup of n = 902 hospital admitted patients in whom no rhythm control [i.e. pharmacological cardioversion (PCV), electrical cardioversion (ECV), and catheter ablation] was performed or planned at initial presentation (as recorded by the investigators). Patients in South countries were older (P < 0.0001) but the proportion of females were non-significantly different. In the West countries, the commonest reason for hospital admission was AF (48.8%) and heart failure (18.4%), while in East and South countries, heart failure (34.2 and 33.0%, respectively) was the commonest reason (Figure 1).

Table 1

Patient characteristics and antithrombotic drug use of hospital-admitted patients in whom no PCV and ECV and catheter ablation were performed or planned

	Wholecohort	West	East	South	P-value
	Wholecohort	Belgium, Denmark, Netherlands, Norway	Poland, Romania	Greece, Italy, Portugal
	N = 902	N = 125	N = 462	N = 315
Demographics:
Age (years) (mean ± SD)	71.2 ± 11.3	70.2 ± 12.2	69.1 ± 10.7	74.5 ± 11.0	<0.0001
Age (years) (median, IQR)	73 (64–79)	73 (64–78)	69 (62–77)	76 (69–82)	<0.0001
Female gender (%)	41.0	36.8	44.2	38.1	0.1414
Type of AF:
First detected (%)	36.5	30.5	32.7	44.2	<0.0001
Paroxysmal (%)	19.0	40.7	18.8	11.2
Persistent (%)	12.5	9.3	12.5	13.8
Long standing persistent (%)	2.4	2.5	4.0	0.0
Permanent (%)	29.5	17.0	32.0	30.8
Reason for visit:
AF (%)	31.6	48.8	33.1	22.5	<0.0001
Acute myocardial infarction (%)	8.2	7.2	6.7	10.8
Valvular heart disease (%)	7.1	4.0	4.8	11.8
Hypertension (%)	1.3	1.6	2.2	0.0
Heart failure (%)	31.6	18.4	34.2	33.0
Other coronary artery disease (%)	8.9	5.6	10.6	7.6
Other cardiac (%)	8.5	11.2	5.8	11.4
Other non-cardiac reason (%)	2.8	3.2	2.6	2.9
Past medical history
Ischaemic thromboembolic complications (%)	16.6	13.0	15.8	19.2	0.2350
Previous TIA (%)	4.8	3.3	2.6	8.6	0.0005
Previous stroke (%)	7.9	6.5	8.9	7.0	0.5224
Chronic heart failure (%)	63.4	34.8	72.7	60.1	<0.0001
Hypertension (%)	74.1	56.8	75.9	78.2	<0.0001
Coronary artery disease (%)	47.6	41.8	49.6	46.8	0.3629
Peripheral vascular disease (%)	15.0	2.9	10.8	25.2	<0.0001
Diabetes mellitus (%)	26.7	22.4	27.6	27.1	0.5014
Haemorrhagic events (%)	9.2	3.3	6.1	15.9	<0.0001
Malignancy (%)	4.6	5.7	3.5	5.7	0.3078
Chronic kidney disease (%)	21.6	6.4	22.5	26.4	<0.0001
CHADS₂ score:
0	6.6	20.0	5.0	3.8	<0.0001
1	18.6	21.6	18.8	17.1
≥2	74.7	58.4	76.2	79.1
CHAD₂DS₂-VASc score:
0	2.1	6.4	2.0	0.6	<0.0001
1	5.8	12.8	5.0	4.1
≥2	92.1	80.8	93.0	95.3
HAS-BLED score
0–2	79.9	95.2	82.0	70.8	<0.0001
≥3	20.1	4.8	18.0	29.2	<0.0001
Antithrombotic treatment at discharge:
None and Unknown	2.7	7.2	2.4	1.3	0.0064
OAC alone	53.4	56.8	54.6	50.5
AP alone	14.1	13.6	15.4	12.4
OAC + AP	21.4	15.2	20.1	25.7
Other^a	8.4	7.2	7.6	10.2
Initial management strategy:
Rate control only (%)	63.5	46.4	58.4	77.8	<0.0001
Rate and rhythm control (%)	24.6	36.8	32.0	8.9
Rhythm control only (%)	5.5	6.4	7.6	2.2
Observation (%)	6.3	10.4	2.0	11.1

	Wholecohort	West	East	South	P-value
	Wholecohort	Belgium, Denmark, Netherlands, Norway	Poland, Romania	Greece, Italy, Portugal
	N = 902	N = 125	N = 462	N = 315
Demographics:
Age (years) (mean ± SD)	71.2 ± 11.3	70.2 ± 12.2	69.1 ± 10.7	74.5 ± 11.0	<0.0001
Age (years) (median, IQR)	73 (64–79)	73 (64–78)	69 (62–77)	76 (69–82)	<0.0001
Female gender (%)	41.0	36.8	44.2	38.1	0.1414
Type of AF:
First detected (%)	36.5	30.5	32.7	44.2	<0.0001
Paroxysmal (%)	19.0	40.7	18.8	11.2
Persistent (%)	12.5	9.3	12.5	13.8
Long standing persistent (%)	2.4	2.5	4.0	0.0
Permanent (%)	29.5	17.0	32.0	30.8
Reason for visit:
AF (%)	31.6	48.8	33.1	22.5	<0.0001
Acute myocardial infarction (%)	8.2	7.2	6.7	10.8
Valvular heart disease (%)	7.1	4.0	4.8	11.8
Hypertension (%)	1.3	1.6	2.2	0.0
Heart failure (%)	31.6	18.4	34.2	33.0
Other coronary artery disease (%)	8.9	5.6	10.6	7.6
Other cardiac (%)	8.5	11.2	5.8	11.4
Other non-cardiac reason (%)	2.8	3.2	2.6	2.9
Past medical history
Ischaemic thromboembolic complications (%)	16.6	13.0	15.8	19.2	0.2350
Previous TIA (%)	4.8	3.3	2.6	8.6	0.0005
Previous stroke (%)	7.9	6.5	8.9	7.0	0.5224
Chronic heart failure (%)	63.4	34.8	72.7	60.1	<0.0001
Hypertension (%)	74.1	56.8	75.9	78.2	<0.0001
Coronary artery disease (%)	47.6	41.8	49.6	46.8	0.3629
Peripheral vascular disease (%)	15.0	2.9	10.8	25.2	<0.0001
Diabetes mellitus (%)	26.7	22.4	27.6	27.1	0.5014
Haemorrhagic events (%)	9.2	3.3	6.1	15.9	<0.0001
Malignancy (%)	4.6	5.7	3.5	5.7	0.3078
Chronic kidney disease (%)	21.6	6.4	22.5	26.4	<0.0001
CHADS₂ score:
0	6.6	20.0	5.0	3.8	<0.0001
1	18.6	21.6	18.8	17.1
≥2	74.7	58.4	76.2	79.1
CHAD₂DS₂-VASc score:
0	2.1	6.4	2.0	0.6	<0.0001
1	5.8	12.8	5.0	4.1
≥2	92.1	80.8	93.0	95.3
HAS-BLED score
0–2	79.9	95.2	82.0	70.8	<0.0001
≥3	20.1	4.8	18.0	29.2	<0.0001
Antithrombotic treatment at discharge:
None and Unknown	2.7	7.2	2.4	1.3	0.0064
OAC alone	53.4	56.8	54.6	50.5
AP alone	14.1	13.6	15.4	12.4
OAC + AP	21.4	15.2	20.1	25.7
Other^a	8.4	7.2	7.6	10.2
Initial management strategy:
Rate control only (%)	63.5	46.4	58.4	77.8	<0.0001
Rate and rhythm control (%)	24.6	36.8	32.0	8.9
Rhythm control only (%)	5.5	6.4	7.6	2.2
Observation (%)	6.3	10.4	2.0	11.1

^aOthers include: OAC + other ATT, AP + other ATT, OAC + AP + other ATT and Other ATT (fondaparinux, LMW heparin, UF heparin, other).

Table 1

Patient characteristics and antithrombotic drug use of hospital-admitted patients in whom no PCV and ECV and catheter ablation were performed or planned

	Wholecohort	West	East	South	P-value
	Wholecohort	Belgium, Denmark, Netherlands, Norway	Poland, Romania	Greece, Italy, Portugal
	N = 902	N = 125	N = 462	N = 315
Demographics:
Age (years) (mean ± SD)	71.2 ± 11.3	70.2 ± 12.2	69.1 ± 10.7	74.5 ± 11.0	<0.0001
Age (years) (median, IQR)	73 (64–79)	73 (64–78)	69 (62–77)	76 (69–82)	<0.0001
Female gender (%)	41.0	36.8	44.2	38.1	0.1414
Type of AF:
First detected (%)	36.5	30.5	32.7	44.2	<0.0001
Paroxysmal (%)	19.0	40.7	18.8	11.2
Persistent (%)	12.5	9.3	12.5	13.8
Long standing persistent (%)	2.4	2.5	4.0	0.0
Permanent (%)	29.5	17.0	32.0	30.8
Reason for visit:
AF (%)	31.6	48.8	33.1	22.5	<0.0001
Acute myocardial infarction (%)	8.2	7.2	6.7	10.8
Valvular heart disease (%)	7.1	4.0	4.8	11.8
Hypertension (%)	1.3	1.6	2.2	0.0
Heart failure (%)	31.6	18.4	34.2	33.0
Other coronary artery disease (%)	8.9	5.6	10.6	7.6
Other cardiac (%)	8.5	11.2	5.8	11.4
Other non-cardiac reason (%)	2.8	3.2	2.6	2.9
Past medical history
Ischaemic thromboembolic complications (%)	16.6	13.0	15.8	19.2	0.2350
Previous TIA (%)	4.8	3.3	2.6	8.6	0.0005
Previous stroke (%)	7.9	6.5	8.9	7.0	0.5224
Chronic heart failure (%)	63.4	34.8	72.7	60.1	<0.0001
Hypertension (%)	74.1	56.8	75.9	78.2	<0.0001
Coronary artery disease (%)	47.6	41.8	49.6	46.8	0.3629
Peripheral vascular disease (%)	15.0	2.9	10.8	25.2	<0.0001
Diabetes mellitus (%)	26.7	22.4	27.6	27.1	0.5014
Haemorrhagic events (%)	9.2	3.3	6.1	15.9	<0.0001
Malignancy (%)	4.6	5.7	3.5	5.7	0.3078
Chronic kidney disease (%)	21.6	6.4	22.5	26.4	<0.0001
CHADS₂ score:
0	6.6	20.0	5.0	3.8	<0.0001
1	18.6	21.6	18.8	17.1
≥2	74.7	58.4	76.2	79.1
CHAD₂DS₂-VASc score:
0	2.1	6.4	2.0	0.6	<0.0001
1	5.8	12.8	5.0	4.1
≥2	92.1	80.8	93.0	95.3
HAS-BLED score
0–2	79.9	95.2	82.0	70.8	<0.0001
≥3	20.1	4.8	18.0	29.2	<0.0001
Antithrombotic treatment at discharge:
None and Unknown	2.7	7.2	2.4	1.3	0.0064
OAC alone	53.4	56.8	54.6	50.5
AP alone	14.1	13.6	15.4	12.4
OAC + AP	21.4	15.2	20.1	25.7
Other^a	8.4	7.2	7.6	10.2
Initial management strategy:
Rate control only (%)	63.5	46.4	58.4	77.8	<0.0001
Rate and rhythm control (%)	24.6	36.8	32.0	8.9
Rhythm control only (%)	5.5	6.4	7.6	2.2
Observation (%)	6.3	10.4	2.0	11.1

	Wholecohort	West	East	South	P-value
	Wholecohort	Belgium, Denmark, Netherlands, Norway	Poland, Romania	Greece, Italy, Portugal
	N = 902	N = 125	N = 462	N = 315
Demographics:
Age (years) (mean ± SD)	71.2 ± 11.3	70.2 ± 12.2	69.1 ± 10.7	74.5 ± 11.0	<0.0001
Age (years) (median, IQR)	73 (64–79)	73 (64–78)	69 (62–77)	76 (69–82)	<0.0001
Female gender (%)	41.0	36.8	44.2	38.1	0.1414
Type of AF:
First detected (%)	36.5	30.5	32.7	44.2	<0.0001
Paroxysmal (%)	19.0	40.7	18.8	11.2
Persistent (%)	12.5	9.3	12.5	13.8
Long standing persistent (%)	2.4	2.5	4.0	0.0
Permanent (%)	29.5	17.0	32.0	30.8
Reason for visit:
AF (%)	31.6	48.8	33.1	22.5	<0.0001
Acute myocardial infarction (%)	8.2	7.2	6.7	10.8
Valvular heart disease (%)	7.1	4.0	4.8	11.8
Hypertension (%)	1.3	1.6	2.2	0.0
Heart failure (%)	31.6	18.4	34.2	33.0
Other coronary artery disease (%)	8.9	5.6	10.6	7.6
Other cardiac (%)	8.5	11.2	5.8	11.4
Other non-cardiac reason (%)	2.8	3.2	2.6	2.9
Past medical history
Ischaemic thromboembolic complications (%)	16.6	13.0	15.8	19.2	0.2350
Previous TIA (%)	4.8	3.3	2.6	8.6	0.0005
Previous stroke (%)	7.9	6.5	8.9	7.0	0.5224
Chronic heart failure (%)	63.4	34.8	72.7	60.1	<0.0001
Hypertension (%)	74.1	56.8	75.9	78.2	<0.0001
Coronary artery disease (%)	47.6	41.8	49.6	46.8	0.3629
Peripheral vascular disease (%)	15.0	2.9	10.8	25.2	<0.0001
Diabetes mellitus (%)	26.7	22.4	27.6	27.1	0.5014
Haemorrhagic events (%)	9.2	3.3	6.1	15.9	<0.0001
Malignancy (%)	4.6	5.7	3.5	5.7	0.3078
Chronic kidney disease (%)	21.6	6.4	22.5	26.4	<0.0001
CHADS₂ score:
0	6.6	20.0	5.0	3.8	<0.0001
1	18.6	21.6	18.8	17.1
≥2	74.7	58.4	76.2	79.1
CHAD₂DS₂-VASc score:
0	2.1	6.4	2.0	0.6	<0.0001
1	5.8	12.8	5.0	4.1
≥2	92.1	80.8	93.0	95.3
HAS-BLED score
0–2	79.9	95.2	82.0	70.8	<0.0001
≥3	20.1	4.8	18.0	29.2	<0.0001
Antithrombotic treatment at discharge:
None and Unknown	2.7	7.2	2.4	1.3	0.0064
OAC alone	53.4	56.8	54.6	50.5
AP alone	14.1	13.6	15.4	12.4
OAC + AP	21.4	15.2	20.1	25.7
Other^a	8.4	7.2	7.6	10.2
Initial management strategy:
Rate control only (%)	63.5	46.4	58.4	77.8	<0.0001
Rate and rhythm control (%)	24.6	36.8	32.0	8.9
Rhythm control only (%)	5.5	6.4	7.6	2.2
Observation (%)	6.3	10.4	2.0	11.1

^aOthers include: OAC + other ATT, AP + other ATT, OAC + AP + other ATT and Other ATT (fondaparinux, LMW heparin, UF heparin, other).

Figure 1

Antithrombotic drug prescription at inclusion and at discharge in patients undergoing cardioversion or ablation. (A) Pharmacological cardioversion by zone. (B) Electrical cardioversion by zone. (C) Catheter ablation by zone.

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Previous stroke/thromboembolism, coronary artery disease, diabetes, or malignancy were not significantly different between regions, but previous transient ischaemic attack (TIA) was more prevalent in South countries. Chronic heart failure was more common in East countries (P < 0.0001), while hypertension and peripheral artery disease were more common in South countries (both P < 0.0001). Previous bleeding and chronic kidney disease were more common in South countries (both P < 0.0001).

The proportion with a CHADS₂ score of ≥2 was highest in East and South countries (76.2 and 79.1%, respectively) compared with 58.4% in West countries. A CHA₂DS₂-VASc score of ≥2 was also highest in East and South countries (93.0 and 95.3%, respectively) compared with 80.8% in West countries (P < 0.0001). A HAS-BLED score of ≥3 was also highest in East and South countries (18.0 and 29.2%, respectively) compared with 4.8% in West countries (P < 0.0001).

Oral anticoagulation (OAC) use (either as OAC or OAC plus antiplatelet therapy) in West, East, and South countries was 72.0, 74.7, and 76.2%, respectively. Antiplatelet therapy use alone was used in 13.6, 15.4, and 12.4%, respectively. An initial rate control strategy only was most common in South countries (77.8%) (P < 0.0001).

Determinants of antithrombotic therapy use by region

The factors predictive of OAC monotherapy [VKAs or Non-vitamin K antagonist oral anticoagulant (NOAC)] prescription in West countries were lack of coronary artery disease (P < 0.0001) and hypertension (P = 0.0275). In East countries, predictive factors were younger age (P = 0.0026), female gender (P = 0.0112), non-valvular heart disease (P = 0.0048), no chronic heart failure (P = 0.0043), lack of coronary/peripheral artery disease (P < 0.0001), and non-rhythm control (P = 0.006). In South countries, female gender (P = 0.0284), no coronary artery disease (P < 0.0001), no diabetes (P = 0.0079), and type of AF (P = 0.0386) were predictive factors (Table 2).

Table 2

Factors associated with prescription of antithrombotic therapy

	Odds ratio	95% Confidence limits		P-value
(a) Factors associated with prescription of OAC alone (VKAs plus NOACs)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.2543	0.9127	1.7236	0.1621
Female gender (%)	1.0431	0.7489	1.4529	0.8029
Valvular heart disease (%)	0.8133	0.5828	1.1351	0.2241
Previous TIA/Stroke (%)	1.0740	0.6258	1.8432	0.7955
Chronic heart failure (%)	0.7526	0.5098	1.1109	0.1518
Hypertension (%)	1.4227	1.0392	1.9477	0.0275
CAD (%)	0.2021	0.1374	0.2974	<0.0001
PAD (%)	0.5755	0.2480	1.3352	0.1931
Diabetes mellitus (%)	0.9838	0.6376	1.5180	0.9413
Type of AF (%) (ref. = first detected)	0.7517	0.5238	1.0787	0.1208
Heart rhythm strategy (%) (ref. = others)	0.8059	0.5523	1.1759	0.2625
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.7108	0.5692	0.8877	0.0026
Female gender (%)	1.3266	1.0661	1.6506	0.0112
Valvular heart disease (%)	0.7015	0.5480	0.8980	0.0048
Previous TIA/Stroke (%)	1.4155	0.9494	2.1105	0.0869
Chronic heart failure (%)	0.7054	0.5549	0.8967	0.0043
Hypertension (%)	0.9859	0.7620	1.2754	0.9137
CAD (%)	0.2305	0.1791	0.2967	<0.0001
PAD (%)	0.4664	0.3256	0.6683	<0.0001
Diabetes mellitus (%)	0.8378	0.6489	1.0816	0.1742
Type of AF (%) (ref. = first detected)	1.1050	0.8703	1.4030	0.4124
Heart rhythm strategy (%) (ref. = others)	1.7157	1.1635	2.5298	0.0060
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	1.0803	0.8253	1.4141	0.5739
Female gender (%)	1.3252	1.0300	1.7050	0.0284
Valvular heart disease (%)	0.7915	0.6034	1.0384	0.0912
Previous TIA/Stroke (%)	1.1948	0.7986	1.7875	0.3862
Chronic heart failure (%)	0.8793	0.6779	1.1406	0.3324
Hypertension (%)	1.0721	0.8136	1.4127	0.6209
CAD (%)	0.1332	0.0973	0.1825	<0.0001
PAD (%)	0.7466	0.5322	1.0471	0.0897
Diabetes mellitus (%)	0.6638	0.4901	0.8990	0.0079
Type of AF (%) (ref. = first detected)	0.7637	0.5914	0.9862	0.0386
Heart rhythm strategy (%) (ref. = others)	0.8203	0.5677	1.1852	0.2908
(b) Factors associated with prescription of NOACs only (dabigatran or rivaroxaban)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.1037	0.7318	1.6645	0.6378
Female gender (%)	1.1667	0.7719	1.7634	0.4643
Valvular heart disease (%)	1.1315	0.7510	1.7048	0.5545
Previous TIA/stroke (%)	1.4000	0.7531	2.6026	0.2856
Chronic heart failure (%)	0.8531	0.5100	1.4271	0.5448
Hypertension (%)	1.2345	0.8212	1.8558	0.3106
CAD (%)	0.6152	0.3569	1.0606	0.0782
PAD (%)	1.3116	0.4358	3.9469	0.5475
Diabetes mellitus (%)	1.1209	0.6552	1.9175	0.6769
Type of AF (%) (ref. = first detected)	1.5918	1.0264	2.4685	0.0367
Heart rhythm strategy (%) (ref. = others)	0.7400	0.4370	1.2532	0.2612
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.9828	0.6464	1.4941	0.9352
Female gender (%)	1.1136	0.7375	1.6817	0.6087
Reason for visit (%) (ref. = atrial fibrillation)	1.3128	0.8640	1.9947	0.2012
Valvular heart disease (%)	0.6629	0.4281	1.0266	0.0639
Previous TIA/stroke (%)	2.1192	1.1755	3.8206	0.0108
Chronic heart failure (%)	0.7198	0.4681	1.1069	0.1328
Hypertension (%)	1.2601	0.7500	2.1170	0.3816
CAD (%)	0.5051	0.3119	0.8182	0.0048
PAD (%)	0.5947	0.2700	1.3096	0.1922
Diabetes mellitus (%)	0.9724	0.5983	1.5803	0.9099
Type of AF (%) (ref. = first detected)	1.7463	1.1453	2.6627	0.0089
Heart rhythm strategy (%) (ref. = others)	2.0713	1.1689	3.6705	0.0110
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.3531	0.1993	0.6255	0.0002
Female gender (%)	0.9532	0.5310	1.7112	0.8725
Valvular heart disease (%)	0.2875	0.1543	0.5357	<0.0001
Previous TIA/Stroke (%)	1.1578	0.4818	2.7825	0.7431
Chronic heart failure (%)	0.5697	0.2836	1.1444	0.1096
Hypertension (%)	0.6391	0.3527	1.1582	0.1371
CAD (%)	0.3281	0.1265	0.8507	0.0161
PAD (%)	0.3478	0.1068	1.1324	0.0668
Diabetes mellitus (%)	0.5336	0.2240	1.2710	0.1498
Type of AF (%) (ref. = first detected)	0.5099	0.2579	1.0081	0.0489
Heart rhythm strategy (%) (ref. = others)	2.3443	1.1914	4.6130	0.0113
(c) Factors associated with prescription of antiplatelet drugs alone
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	0.5795	0.3279	1.0241	0.0578
Female gender (%)	1.1900	0.6606	2.1435	0.5620
Valvular heart disease (%)	1.3490	0.7174	2.5365	0.3513
Previous TIA/stroke (%)	0.5863	0.1779	1.9329	0.6160
Chronic heart failure (%)	1.1033	0.5309	2.2928	0.7922
Hypertension (%)	0.4606	0.2575	0.8239	0.0077
CAD (%)	2.8085	1.4557	5.4186	0.0014
PAD (%)	0.5502	0.0726	4.1704	>0.9999
Diabetes mellitus (%)	0.7279	0.3033	1.7471	0.4755
Type of AF (%) (ref. = first detected)	1.0394	0.5318	2.0314	0.9100
Heart rhythm strategy (%) (ref. = rhythm control only)	1.5215	0.8009	2.8903	0.1971
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.8291	1.3151	2.5439	0.0003
Female gender (%)	1.2384	0.9149	1.6762	0.1658
Valvular heart disease (%)	0.8359	0.5994	1.1657	0.2903
Previous TIA/stroke (%)	0.6723	0.3615	1.2500	0.2068
Chronic heart failure (%)	0.9589	0.6901	1.3324	0.8026
Hypertension (%)	0.9265	0.6502	1.3203	0.6727
CAD (%)	1.7368	1.2489	2.4152	0.0009
PAD (%)	0.6608	0.3838	1.1375	0.1325
Diabetes mellitus (%)	0.6988	0.4766	1.0248	0.0655
Type of AF (%) (ref. = first detected)	1.7191	1.2557	2.3535	0.0007
Heart rhythm strategy (%) (ref. = rhythm control only)	1.2883	0.7898	2.1014	0.3092
Zone 3: SOUTH (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.6352	0.4434	0.9097	0.0128
Female gender (%)	1.1078	0.7814	1.5706	0.5652
Reason for visit (%) (ref. = AF)	1.0985	0.7772	1.5527	0.5946
Valvular heart disease (%)	0.8239	0.5672	1.1967	0.3087
Previous TIA/stroke (%)	0.4845	0.2395	0.9802	0.0398
Chronic heart failure (%)	0.2989	0.1887	0.4733	<0.0001
Hypertension (%)	1.0359	0.7011	1.5305	0.8594
CAD (%)	1.1160	0.7569	1.6455	0.5795
PAD (%)	0.9819	0.6077	1.5865	0.9406
Diabetes mellitus (%)	0.7009	0.4403	1.1157	0.1324
Type of AF (%) (ref. = first detected)	1.1999	0.8425	1.7091	0.3120
Heart rhythm strategy (%) (ref. = rhythm control only)	1.6394	1.0312	2.6063	0.0351
(d) Factors associated with prescription of combination OAC + antiplatelet drugs
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.9356	1.1867	3.1572	0.0073
Female gender (%)	0.8845	0.5546	1.4106	0.6061
Valvular heart disease (%)	1.4107	0.9073	2.1933	0.1253
Previous TIA/stroke (%)	1.1769	0.5810	2.3840	0.6507
Chronic heart failure (%)	1.5397	0.9383	2.5264	0.0859
Hypertension (%)	1.9886	1.2393	3.1909	0.0039
CAD (%)	6.4000	3.9741	10.3067	<0.0001
PAD (%)	4.6085	1.9295	11.0075	0.0014
Diabetes mellitus (%)	1.5117	0.8742	2.6141	0.1369
Type of AF (%) (ref. = first detected)	0.9132	0.5397	1.5454	0.7352
Heart rhythm strategy (%) (ref. = rhythm control only)	1.1581	0.6877	1.9503	0.5807
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.3314	1.0247	1.7298	0.0318
Female gender (%)	0.6946	0.5370	0.8984	0.0054
Valvular heart disease (%)	2.0471	1.4914	2.8098	<0.0001
Previous TIA/stroke (%)	0.9922	0.6260	1.5724	0.9733
Chronic heart failure (%)	1.8819	1.3928	2.5427	<0.0001
Hypertension (%)	1.4546	1.0589	1.9983	0.0202
CAD (%)	5.1507	3.8039	6.9744	<0.0001
PAD (%)	2.4907	1.7426	3.5599	<0.0001
Diabetes mellitus (%)	1.6023	1.2069	2.1270	0.0010
Type of AF (%) (ref. = first detected)	0.7389	0.5541	0.9854	0.0390
Heart rhythm strategy (%) (ref. = rhythm control only)	0.4464	0.2595	0.7677	0.0028
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	2.5456	1.6490	3.9297	<0.0001
Female gender (%)	0.4779	0.3319	0.6881	<0.0001
Valvular heart disease (%)	1.7361	1.1890	2.5350	0.0040
Previous TIA/stroke (%)	1.6033	0.9988	2.5739	0.0489
Chronic heart failure (%)	2.5786	1.8496	3.5949	<0.0001
Hypertension (%)	1.7333	1.1545	2.6023	0.0074
CAD (%)	19.7886	12.7869	30.6241	<0.0001
PAD (%)	2.1623	1.4587	3.2054	<0.0001
Diabetes mellitus (%)	2.0772	1.4446	2.9868	<0.0001
Type of AF (%) (ref. = first detected)	0.9548	0.6786	1.3433	0.7905
Heart rhythm strategy (%) (ref. = rhythm control only)	0.5602	0.3137	1.0005	0.0475

	Odds ratio	95% Confidence limits		P-value
(a) Factors associated with prescription of OAC alone (VKAs plus NOACs)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.2543	0.9127	1.7236	0.1621
Female gender (%)	1.0431	0.7489	1.4529	0.8029
Valvular heart disease (%)	0.8133	0.5828	1.1351	0.2241
Previous TIA/Stroke (%)	1.0740	0.6258	1.8432	0.7955
Chronic heart failure (%)	0.7526	0.5098	1.1109	0.1518
Hypertension (%)	1.4227	1.0392	1.9477	0.0275
CAD (%)	0.2021	0.1374	0.2974	<0.0001
PAD (%)	0.5755	0.2480	1.3352	0.1931
Diabetes mellitus (%)	0.9838	0.6376	1.5180	0.9413
Type of AF (%) (ref. = first detected)	0.7517	0.5238	1.0787	0.1208
Heart rhythm strategy (%) (ref. = others)	0.8059	0.5523	1.1759	0.2625
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.7108	0.5692	0.8877	0.0026
Female gender (%)	1.3266	1.0661	1.6506	0.0112
Valvular heart disease (%)	0.7015	0.5480	0.8980	0.0048
Previous TIA/Stroke (%)	1.4155	0.9494	2.1105	0.0869
Chronic heart failure (%)	0.7054	0.5549	0.8967	0.0043
Hypertension (%)	0.9859	0.7620	1.2754	0.9137
CAD (%)	0.2305	0.1791	0.2967	<0.0001
PAD (%)	0.4664	0.3256	0.6683	<0.0001
Diabetes mellitus (%)	0.8378	0.6489	1.0816	0.1742
Type of AF (%) (ref. = first detected)	1.1050	0.8703	1.4030	0.4124
Heart rhythm strategy (%) (ref. = others)	1.7157	1.1635	2.5298	0.0060
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	1.0803	0.8253	1.4141	0.5739
Female gender (%)	1.3252	1.0300	1.7050	0.0284
Valvular heart disease (%)	0.7915	0.6034	1.0384	0.0912
Previous TIA/Stroke (%)	1.1948	0.7986	1.7875	0.3862
Chronic heart failure (%)	0.8793	0.6779	1.1406	0.3324
Hypertension (%)	1.0721	0.8136	1.4127	0.6209
CAD (%)	0.1332	0.0973	0.1825	<0.0001
PAD (%)	0.7466	0.5322	1.0471	0.0897
Diabetes mellitus (%)	0.6638	0.4901	0.8990	0.0079
Type of AF (%) (ref. = first detected)	0.7637	0.5914	0.9862	0.0386
Heart rhythm strategy (%) (ref. = others)	0.8203	0.5677	1.1852	0.2908
(b) Factors associated with prescription of NOACs only (dabigatran or rivaroxaban)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.1037	0.7318	1.6645	0.6378
Female gender (%)	1.1667	0.7719	1.7634	0.4643
Valvular heart disease (%)	1.1315	0.7510	1.7048	0.5545
Previous TIA/stroke (%)	1.4000	0.7531	2.6026	0.2856
Chronic heart failure (%)	0.8531	0.5100	1.4271	0.5448
Hypertension (%)	1.2345	0.8212	1.8558	0.3106
CAD (%)	0.6152	0.3569	1.0606	0.0782
PAD (%)	1.3116	0.4358	3.9469	0.5475
Diabetes mellitus (%)	1.1209	0.6552	1.9175	0.6769
Type of AF (%) (ref. = first detected)	1.5918	1.0264	2.4685	0.0367
Heart rhythm strategy (%) (ref. = others)	0.7400	0.4370	1.2532	0.2612
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.9828	0.6464	1.4941	0.9352
Female gender (%)	1.1136	0.7375	1.6817	0.6087
Reason for visit (%) (ref. = atrial fibrillation)	1.3128	0.8640	1.9947	0.2012
Valvular heart disease (%)	0.6629	0.4281	1.0266	0.0639
Previous TIA/stroke (%)	2.1192	1.1755	3.8206	0.0108
Chronic heart failure (%)	0.7198	0.4681	1.1069	0.1328
Hypertension (%)	1.2601	0.7500	2.1170	0.3816
CAD (%)	0.5051	0.3119	0.8182	0.0048
PAD (%)	0.5947	0.2700	1.3096	0.1922
Diabetes mellitus (%)	0.9724	0.5983	1.5803	0.9099
Type of AF (%) (ref. = first detected)	1.7463	1.1453	2.6627	0.0089
Heart rhythm strategy (%) (ref. = others)	2.0713	1.1689	3.6705	0.0110
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.3531	0.1993	0.6255	0.0002
Female gender (%)	0.9532	0.5310	1.7112	0.8725
Valvular heart disease (%)	0.2875	0.1543	0.5357	<0.0001
Previous TIA/Stroke (%)	1.1578	0.4818	2.7825	0.7431
Chronic heart failure (%)	0.5697	0.2836	1.1444	0.1096
Hypertension (%)	0.6391	0.3527	1.1582	0.1371
CAD (%)	0.3281	0.1265	0.8507	0.0161
PAD (%)	0.3478	0.1068	1.1324	0.0668
Diabetes mellitus (%)	0.5336	0.2240	1.2710	0.1498
Type of AF (%) (ref. = first detected)	0.5099	0.2579	1.0081	0.0489
Heart rhythm strategy (%) (ref. = others)	2.3443	1.1914	4.6130	0.0113
(c) Factors associated with prescription of antiplatelet drugs alone
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	0.5795	0.3279	1.0241	0.0578
Female gender (%)	1.1900	0.6606	2.1435	0.5620
Valvular heart disease (%)	1.3490	0.7174	2.5365	0.3513
Previous TIA/stroke (%)	0.5863	0.1779	1.9329	0.6160
Chronic heart failure (%)	1.1033	0.5309	2.2928	0.7922
Hypertension (%)	0.4606	0.2575	0.8239	0.0077
CAD (%)	2.8085	1.4557	5.4186	0.0014
PAD (%)	0.5502	0.0726	4.1704	>0.9999
Diabetes mellitus (%)	0.7279	0.3033	1.7471	0.4755
Type of AF (%) (ref. = first detected)	1.0394	0.5318	2.0314	0.9100
Heart rhythm strategy (%) (ref. = rhythm control only)	1.5215	0.8009	2.8903	0.1971
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.8291	1.3151	2.5439	0.0003
Female gender (%)	1.2384	0.9149	1.6762	0.1658
Valvular heart disease (%)	0.8359	0.5994	1.1657	0.2903
Previous TIA/stroke (%)	0.6723	0.3615	1.2500	0.2068
Chronic heart failure (%)	0.9589	0.6901	1.3324	0.8026
Hypertension (%)	0.9265	0.6502	1.3203	0.6727
CAD (%)	1.7368	1.2489	2.4152	0.0009
PAD (%)	0.6608	0.3838	1.1375	0.1325
Diabetes mellitus (%)	0.6988	0.4766	1.0248	0.0655
Type of AF (%) (ref. = first detected)	1.7191	1.2557	2.3535	0.0007
Heart rhythm strategy (%) (ref. = rhythm control only)	1.2883	0.7898	2.1014	0.3092
Zone 3: SOUTH (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.6352	0.4434	0.9097	0.0128
Female gender (%)	1.1078	0.7814	1.5706	0.5652
Reason for visit (%) (ref. = AF)	1.0985	0.7772	1.5527	0.5946
Valvular heart disease (%)	0.8239	0.5672	1.1967	0.3087
Previous TIA/stroke (%)	0.4845	0.2395	0.9802	0.0398
Chronic heart failure (%)	0.2989	0.1887	0.4733	<0.0001
Hypertension (%)	1.0359	0.7011	1.5305	0.8594
CAD (%)	1.1160	0.7569	1.6455	0.5795
PAD (%)	0.9819	0.6077	1.5865	0.9406
Diabetes mellitus (%)	0.7009	0.4403	1.1157	0.1324
Type of AF (%) (ref. = first detected)	1.1999	0.8425	1.7091	0.3120
Heart rhythm strategy (%) (ref. = rhythm control only)	1.6394	1.0312	2.6063	0.0351
(d) Factors associated with prescription of combination OAC + antiplatelet drugs
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.9356	1.1867	3.1572	0.0073
Female gender (%)	0.8845	0.5546	1.4106	0.6061
Valvular heart disease (%)	1.4107	0.9073	2.1933	0.1253
Previous TIA/stroke (%)	1.1769	0.5810	2.3840	0.6507
Chronic heart failure (%)	1.5397	0.9383	2.5264	0.0859
Hypertension (%)	1.9886	1.2393	3.1909	0.0039
CAD (%)	6.4000	3.9741	10.3067	<0.0001
PAD (%)	4.6085	1.9295	11.0075	0.0014
Diabetes mellitus (%)	1.5117	0.8742	2.6141	0.1369
Type of AF (%) (ref. = first detected)	0.9132	0.5397	1.5454	0.7352
Heart rhythm strategy (%) (ref. = rhythm control only)	1.1581	0.6877	1.9503	0.5807
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.3314	1.0247	1.7298	0.0318
Female gender (%)	0.6946	0.5370	0.8984	0.0054
Valvular heart disease (%)	2.0471	1.4914	2.8098	<0.0001
Previous TIA/stroke (%)	0.9922	0.6260	1.5724	0.9733
Chronic heart failure (%)	1.8819	1.3928	2.5427	<0.0001
Hypertension (%)	1.4546	1.0589	1.9983	0.0202
CAD (%)	5.1507	3.8039	6.9744	<0.0001
PAD (%)	2.4907	1.7426	3.5599	<0.0001
Diabetes mellitus (%)	1.6023	1.2069	2.1270	0.0010
Type of AF (%) (ref. = first detected)	0.7389	0.5541	0.9854	0.0390
Heart rhythm strategy (%) (ref. = rhythm control only)	0.4464	0.2595	0.7677	0.0028
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	2.5456	1.6490	3.9297	<0.0001
Female gender (%)	0.4779	0.3319	0.6881	<0.0001
Valvular heart disease (%)	1.7361	1.1890	2.5350	0.0040
Previous TIA/stroke (%)	1.6033	0.9988	2.5739	0.0489
Chronic heart failure (%)	2.5786	1.8496	3.5949	<0.0001
Hypertension (%)	1.7333	1.1545	2.6023	0.0074
CAD (%)	19.7886	12.7869	30.6241	<0.0001
PAD (%)	2.1623	1.4587	3.2054	<0.0001
Diabetes mellitus (%)	2.0772	1.4446	2.9868	<0.0001
Type of AF (%) (ref. = first detected)	0.9548	0.6786	1.3433	0.7905
Heart rhythm strategy (%) (ref. = rhythm control only)	0.5602	0.3137	1.0005	0.0475

CAD, coronary artery disease; PAD, peripheral vascular disease.

Table 2

Factors associated with prescription of antithrombotic therapy

	Odds ratio	95% Confidence limits		P-value
(a) Factors associated with prescription of OAC alone (VKAs plus NOACs)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.2543	0.9127	1.7236	0.1621
Female gender (%)	1.0431	0.7489	1.4529	0.8029
Valvular heart disease (%)	0.8133	0.5828	1.1351	0.2241
Previous TIA/Stroke (%)	1.0740	0.6258	1.8432	0.7955
Chronic heart failure (%)	0.7526	0.5098	1.1109	0.1518
Hypertension (%)	1.4227	1.0392	1.9477	0.0275
CAD (%)	0.2021	0.1374	0.2974	<0.0001
PAD (%)	0.5755	0.2480	1.3352	0.1931
Diabetes mellitus (%)	0.9838	0.6376	1.5180	0.9413
Type of AF (%) (ref. = first detected)	0.7517	0.5238	1.0787	0.1208
Heart rhythm strategy (%) (ref. = others)	0.8059	0.5523	1.1759	0.2625
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.7108	0.5692	0.8877	0.0026
Female gender (%)	1.3266	1.0661	1.6506	0.0112
Valvular heart disease (%)	0.7015	0.5480	0.8980	0.0048
Previous TIA/Stroke (%)	1.4155	0.9494	2.1105	0.0869
Chronic heart failure (%)	0.7054	0.5549	0.8967	0.0043
Hypertension (%)	0.9859	0.7620	1.2754	0.9137
CAD (%)	0.2305	0.1791	0.2967	<0.0001
PAD (%)	0.4664	0.3256	0.6683	<0.0001
Diabetes mellitus (%)	0.8378	0.6489	1.0816	0.1742
Type of AF (%) (ref. = first detected)	1.1050	0.8703	1.4030	0.4124
Heart rhythm strategy (%) (ref. = others)	1.7157	1.1635	2.5298	0.0060
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	1.0803	0.8253	1.4141	0.5739
Female gender (%)	1.3252	1.0300	1.7050	0.0284
Valvular heart disease (%)	0.7915	0.6034	1.0384	0.0912
Previous TIA/Stroke (%)	1.1948	0.7986	1.7875	0.3862
Chronic heart failure (%)	0.8793	0.6779	1.1406	0.3324
Hypertension (%)	1.0721	0.8136	1.4127	0.6209
CAD (%)	0.1332	0.0973	0.1825	<0.0001
PAD (%)	0.7466	0.5322	1.0471	0.0897
Diabetes mellitus (%)	0.6638	0.4901	0.8990	0.0079
Type of AF (%) (ref. = first detected)	0.7637	0.5914	0.9862	0.0386
Heart rhythm strategy (%) (ref. = others)	0.8203	0.5677	1.1852	0.2908
(b) Factors associated with prescription of NOACs only (dabigatran or rivaroxaban)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.1037	0.7318	1.6645	0.6378
Female gender (%)	1.1667	0.7719	1.7634	0.4643
Valvular heart disease (%)	1.1315	0.7510	1.7048	0.5545
Previous TIA/stroke (%)	1.4000	0.7531	2.6026	0.2856
Chronic heart failure (%)	0.8531	0.5100	1.4271	0.5448
Hypertension (%)	1.2345	0.8212	1.8558	0.3106
CAD (%)	0.6152	0.3569	1.0606	0.0782
PAD (%)	1.3116	0.4358	3.9469	0.5475
Diabetes mellitus (%)	1.1209	0.6552	1.9175	0.6769
Type of AF (%) (ref. = first detected)	1.5918	1.0264	2.4685	0.0367
Heart rhythm strategy (%) (ref. = others)	0.7400	0.4370	1.2532	0.2612
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.9828	0.6464	1.4941	0.9352
Female gender (%)	1.1136	0.7375	1.6817	0.6087
Reason for visit (%) (ref. = atrial fibrillation)	1.3128	0.8640	1.9947	0.2012
Valvular heart disease (%)	0.6629	0.4281	1.0266	0.0639
Previous TIA/stroke (%)	2.1192	1.1755	3.8206	0.0108
Chronic heart failure (%)	0.7198	0.4681	1.1069	0.1328
Hypertension (%)	1.2601	0.7500	2.1170	0.3816
CAD (%)	0.5051	0.3119	0.8182	0.0048
PAD (%)	0.5947	0.2700	1.3096	0.1922
Diabetes mellitus (%)	0.9724	0.5983	1.5803	0.9099
Type of AF (%) (ref. = first detected)	1.7463	1.1453	2.6627	0.0089
Heart rhythm strategy (%) (ref. = others)	2.0713	1.1689	3.6705	0.0110
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.3531	0.1993	0.6255	0.0002
Female gender (%)	0.9532	0.5310	1.7112	0.8725
Valvular heart disease (%)	0.2875	0.1543	0.5357	<0.0001
Previous TIA/Stroke (%)	1.1578	0.4818	2.7825	0.7431
Chronic heart failure (%)	0.5697	0.2836	1.1444	0.1096
Hypertension (%)	0.6391	0.3527	1.1582	0.1371
CAD (%)	0.3281	0.1265	0.8507	0.0161
PAD (%)	0.3478	0.1068	1.1324	0.0668
Diabetes mellitus (%)	0.5336	0.2240	1.2710	0.1498
Type of AF (%) (ref. = first detected)	0.5099	0.2579	1.0081	0.0489
Heart rhythm strategy (%) (ref. = others)	2.3443	1.1914	4.6130	0.0113
(c) Factors associated with prescription of antiplatelet drugs alone
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	0.5795	0.3279	1.0241	0.0578
Female gender (%)	1.1900	0.6606	2.1435	0.5620
Valvular heart disease (%)	1.3490	0.7174	2.5365	0.3513
Previous TIA/stroke (%)	0.5863	0.1779	1.9329	0.6160
Chronic heart failure (%)	1.1033	0.5309	2.2928	0.7922
Hypertension (%)	0.4606	0.2575	0.8239	0.0077
CAD (%)	2.8085	1.4557	5.4186	0.0014
PAD (%)	0.5502	0.0726	4.1704	>0.9999
Diabetes mellitus (%)	0.7279	0.3033	1.7471	0.4755
Type of AF (%) (ref. = first detected)	1.0394	0.5318	2.0314	0.9100
Heart rhythm strategy (%) (ref. = rhythm control only)	1.5215	0.8009	2.8903	0.1971
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.8291	1.3151	2.5439	0.0003
Female gender (%)	1.2384	0.9149	1.6762	0.1658
Valvular heart disease (%)	0.8359	0.5994	1.1657	0.2903
Previous TIA/stroke (%)	0.6723	0.3615	1.2500	0.2068
Chronic heart failure (%)	0.9589	0.6901	1.3324	0.8026
Hypertension (%)	0.9265	0.6502	1.3203	0.6727
CAD (%)	1.7368	1.2489	2.4152	0.0009
PAD (%)	0.6608	0.3838	1.1375	0.1325
Diabetes mellitus (%)	0.6988	0.4766	1.0248	0.0655
Type of AF (%) (ref. = first detected)	1.7191	1.2557	2.3535	0.0007
Heart rhythm strategy (%) (ref. = rhythm control only)	1.2883	0.7898	2.1014	0.3092
Zone 3: SOUTH (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.6352	0.4434	0.9097	0.0128
Female gender (%)	1.1078	0.7814	1.5706	0.5652
Reason for visit (%) (ref. = AF)	1.0985	0.7772	1.5527	0.5946
Valvular heart disease (%)	0.8239	0.5672	1.1967	0.3087
Previous TIA/stroke (%)	0.4845	0.2395	0.9802	0.0398
Chronic heart failure (%)	0.2989	0.1887	0.4733	<0.0001
Hypertension (%)	1.0359	0.7011	1.5305	0.8594
CAD (%)	1.1160	0.7569	1.6455	0.5795
PAD (%)	0.9819	0.6077	1.5865	0.9406
Diabetes mellitus (%)	0.7009	0.4403	1.1157	0.1324
Type of AF (%) (ref. = first detected)	1.1999	0.8425	1.7091	0.3120
Heart rhythm strategy (%) (ref. = rhythm control only)	1.6394	1.0312	2.6063	0.0351
(d) Factors associated with prescription of combination OAC + antiplatelet drugs
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.9356	1.1867	3.1572	0.0073
Female gender (%)	0.8845	0.5546	1.4106	0.6061
Valvular heart disease (%)	1.4107	0.9073	2.1933	0.1253
Previous TIA/stroke (%)	1.1769	0.5810	2.3840	0.6507
Chronic heart failure (%)	1.5397	0.9383	2.5264	0.0859
Hypertension (%)	1.9886	1.2393	3.1909	0.0039
CAD (%)	6.4000	3.9741	10.3067	<0.0001
PAD (%)	4.6085	1.9295	11.0075	0.0014
Diabetes mellitus (%)	1.5117	0.8742	2.6141	0.1369
Type of AF (%) (ref. = first detected)	0.9132	0.5397	1.5454	0.7352
Heart rhythm strategy (%) (ref. = rhythm control only)	1.1581	0.6877	1.9503	0.5807
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.3314	1.0247	1.7298	0.0318
Female gender (%)	0.6946	0.5370	0.8984	0.0054
Valvular heart disease (%)	2.0471	1.4914	2.8098	<0.0001
Previous TIA/stroke (%)	0.9922	0.6260	1.5724	0.9733
Chronic heart failure (%)	1.8819	1.3928	2.5427	<0.0001
Hypertension (%)	1.4546	1.0589	1.9983	0.0202
CAD (%)	5.1507	3.8039	6.9744	<0.0001
PAD (%)	2.4907	1.7426	3.5599	<0.0001
Diabetes mellitus (%)	1.6023	1.2069	2.1270	0.0010
Type of AF (%) (ref. = first detected)	0.7389	0.5541	0.9854	0.0390
Heart rhythm strategy (%) (ref. = rhythm control only)	0.4464	0.2595	0.7677	0.0028
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	2.5456	1.6490	3.9297	<0.0001
Female gender (%)	0.4779	0.3319	0.6881	<0.0001
Valvular heart disease (%)	1.7361	1.1890	2.5350	0.0040
Previous TIA/stroke (%)	1.6033	0.9988	2.5739	0.0489
Chronic heart failure (%)	2.5786	1.8496	3.5949	<0.0001
Hypertension (%)	1.7333	1.1545	2.6023	0.0074
CAD (%)	19.7886	12.7869	30.6241	<0.0001
PAD (%)	2.1623	1.4587	3.2054	<0.0001
Diabetes mellitus (%)	2.0772	1.4446	2.9868	<0.0001
Type of AF (%) (ref. = first detected)	0.9548	0.6786	1.3433	0.7905
Heart rhythm strategy (%) (ref. = rhythm control only)	0.5602	0.3137	1.0005	0.0475

	Odds ratio	95% Confidence limits		P-value
(a) Factors associated with prescription of OAC alone (VKAs plus NOACs)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.2543	0.9127	1.7236	0.1621
Female gender (%)	1.0431	0.7489	1.4529	0.8029
Valvular heart disease (%)	0.8133	0.5828	1.1351	0.2241
Previous TIA/Stroke (%)	1.0740	0.6258	1.8432	0.7955
Chronic heart failure (%)	0.7526	0.5098	1.1109	0.1518
Hypertension (%)	1.4227	1.0392	1.9477	0.0275
CAD (%)	0.2021	0.1374	0.2974	<0.0001
PAD (%)	0.5755	0.2480	1.3352	0.1931
Diabetes mellitus (%)	0.9838	0.6376	1.5180	0.9413
Type of AF (%) (ref. = first detected)	0.7517	0.5238	1.0787	0.1208
Heart rhythm strategy (%) (ref. = others)	0.8059	0.5523	1.1759	0.2625
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.7108	0.5692	0.8877	0.0026
Female gender (%)	1.3266	1.0661	1.6506	0.0112
Valvular heart disease (%)	0.7015	0.5480	0.8980	0.0048
Previous TIA/Stroke (%)	1.4155	0.9494	2.1105	0.0869
Chronic heart failure (%)	0.7054	0.5549	0.8967	0.0043
Hypertension (%)	0.9859	0.7620	1.2754	0.9137
CAD (%)	0.2305	0.1791	0.2967	<0.0001
PAD (%)	0.4664	0.3256	0.6683	<0.0001
Diabetes mellitus (%)	0.8378	0.6489	1.0816	0.1742
Type of AF (%) (ref. = first detected)	1.1050	0.8703	1.4030	0.4124
Heart rhythm strategy (%) (ref. = others)	1.7157	1.1635	2.5298	0.0060
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	1.0803	0.8253	1.4141	0.5739
Female gender (%)	1.3252	1.0300	1.7050	0.0284
Valvular heart disease (%)	0.7915	0.6034	1.0384	0.0912
Previous TIA/Stroke (%)	1.1948	0.7986	1.7875	0.3862
Chronic heart failure (%)	0.8793	0.6779	1.1406	0.3324
Hypertension (%)	1.0721	0.8136	1.4127	0.6209
CAD (%)	0.1332	0.0973	0.1825	<0.0001
PAD (%)	0.7466	0.5322	1.0471	0.0897
Diabetes mellitus (%)	0.6638	0.4901	0.8990	0.0079
Type of AF (%) (ref. = first detected)	0.7637	0.5914	0.9862	0.0386
Heart rhythm strategy (%) (ref. = others)	0.8203	0.5677	1.1852	0.2908
(b) Factors associated with prescription of NOACs only (dabigatran or rivaroxaban)
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.1037	0.7318	1.6645	0.6378
Female gender (%)	1.1667	0.7719	1.7634	0.4643
Valvular heart disease (%)	1.1315	0.7510	1.7048	0.5545
Previous TIA/stroke (%)	1.4000	0.7531	2.6026	0.2856
Chronic heart failure (%)	0.8531	0.5100	1.4271	0.5448
Hypertension (%)	1.2345	0.8212	1.8558	0.3106
CAD (%)	0.6152	0.3569	1.0606	0.0782
PAD (%)	1.3116	0.4358	3.9469	0.5475
Diabetes mellitus (%)	1.1209	0.6552	1.9175	0.6769
Type of AF (%) (ref. = first detected)	1.5918	1.0264	2.4685	0.0367
Heart rhythm strategy (%) (ref. = others)	0.7400	0.4370	1.2532	0.2612
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	0.9828	0.6464	1.4941	0.9352
Female gender (%)	1.1136	0.7375	1.6817	0.6087
Reason for visit (%) (ref. = atrial fibrillation)	1.3128	0.8640	1.9947	0.2012
Valvular heart disease (%)	0.6629	0.4281	1.0266	0.0639
Previous TIA/stroke (%)	2.1192	1.1755	3.8206	0.0108
Chronic heart failure (%)	0.7198	0.4681	1.1069	0.1328
Hypertension (%)	1.2601	0.7500	2.1170	0.3816
CAD (%)	0.5051	0.3119	0.8182	0.0048
PAD (%)	0.5947	0.2700	1.3096	0.1922
Diabetes mellitus (%)	0.9724	0.5983	1.5803	0.9099
Type of AF (%) (ref. = first detected)	1.7463	1.1453	2.6627	0.0089
Heart rhythm strategy (%) (ref. = others)	2.0713	1.1689	3.6705	0.0110
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.3531	0.1993	0.6255	0.0002
Female gender (%)	0.9532	0.5310	1.7112	0.8725
Valvular heart disease (%)	0.2875	0.1543	0.5357	<0.0001
Previous TIA/Stroke (%)	1.1578	0.4818	2.7825	0.7431
Chronic heart failure (%)	0.5697	0.2836	1.1444	0.1096
Hypertension (%)	0.6391	0.3527	1.1582	0.1371
CAD (%)	0.3281	0.1265	0.8507	0.0161
PAD (%)	0.3478	0.1068	1.1324	0.0668
Diabetes mellitus (%)	0.5336	0.2240	1.2710	0.1498
Type of AF (%) (ref. = first detected)	0.5099	0.2579	1.0081	0.0489
Heart rhythm strategy (%) (ref. = others)	2.3443	1.1914	4.6130	0.0113
(c) Factors associated with prescription of antiplatelet drugs alone
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	0.5795	0.3279	1.0241	0.0578
Female gender (%)	1.1900	0.6606	2.1435	0.5620
Valvular heart disease (%)	1.3490	0.7174	2.5365	0.3513
Previous TIA/stroke (%)	0.5863	0.1779	1.9329	0.6160
Chronic heart failure (%)	1.1033	0.5309	2.2928	0.7922
Hypertension (%)	0.4606	0.2575	0.8239	0.0077
CAD (%)	2.8085	1.4557	5.4186	0.0014
PAD (%)	0.5502	0.0726	4.1704	>0.9999
Diabetes mellitus (%)	0.7279	0.3033	1.7471	0.4755
Type of AF (%) (ref. = first detected)	1.0394	0.5318	2.0314	0.9100
Heart rhythm strategy (%) (ref. = rhythm control only)	1.5215	0.8009	2.8903	0.1971
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.8291	1.3151	2.5439	0.0003
Female gender (%)	1.2384	0.9149	1.6762	0.1658
Valvular heart disease (%)	0.8359	0.5994	1.1657	0.2903
Previous TIA/stroke (%)	0.6723	0.3615	1.2500	0.2068
Chronic heart failure (%)	0.9589	0.6901	1.3324	0.8026
Hypertension (%)	0.9265	0.6502	1.3203	0.6727
CAD (%)	1.7368	1.2489	2.4152	0.0009
PAD (%)	0.6608	0.3838	1.1375	0.1325
Diabetes mellitus (%)	0.6988	0.4766	1.0248	0.0655
Type of AF (%) (ref. = first detected)	1.7191	1.2557	2.3535	0.0007
Heart rhythm strategy (%) (ref. = rhythm control only)	1.2883	0.7898	2.1014	0.3092
Zone 3: SOUTH (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	0.6352	0.4434	0.9097	0.0128
Female gender (%)	1.1078	0.7814	1.5706	0.5652
Reason for visit (%) (ref. = AF)	1.0985	0.7772	1.5527	0.5946
Valvular heart disease (%)	0.8239	0.5672	1.1967	0.3087
Previous TIA/stroke (%)	0.4845	0.2395	0.9802	0.0398
Chronic heart failure (%)	0.2989	0.1887	0.4733	<0.0001
Hypertension (%)	1.0359	0.7011	1.5305	0.8594
CAD (%)	1.1160	0.7569	1.6455	0.5795
PAD (%)	0.9819	0.6077	1.5865	0.9406
Diabetes mellitus (%)	0.7009	0.4403	1.1157	0.1324
Type of AF (%) (ref. = first detected)	1.1999	0.8425	1.7091	0.3120
Heart rhythm strategy (%) (ref. = rhythm control only)	1.6394	1.0312	2.6063	0.0351
(d) Factors associated with prescription of combination OAC + antiplatelet drugs
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Age (%) (ref. = ≤65 years)	1.9356	1.1867	3.1572	0.0073
Female gender (%)	0.8845	0.5546	1.4106	0.6061
Valvular heart disease (%)	1.4107	0.9073	2.1933	0.1253
Previous TIA/stroke (%)	1.1769	0.5810	2.3840	0.6507
Chronic heart failure (%)	1.5397	0.9383	2.5264	0.0859
Hypertension (%)	1.9886	1.2393	3.1909	0.0039
CAD (%)	6.4000	3.9741	10.3067	<0.0001
PAD (%)	4.6085	1.9295	11.0075	0.0014
Diabetes mellitus (%)	1.5117	0.8742	2.6141	0.1369
Type of AF (%) (ref. = first detected)	0.9132	0.5397	1.5454	0.7352
Heart rhythm strategy (%) (ref. = rhythm control only)	1.1581	0.6877	1.9503	0.5807
Zone 2: East (Poland, Romania)
Age (%) (ref. = ≤65 years)	1.3314	1.0247	1.7298	0.0318
Female gender (%)	0.6946	0.5370	0.8984	0.0054
Valvular heart disease (%)	2.0471	1.4914	2.8098	<0.0001
Previous TIA/stroke (%)	0.9922	0.6260	1.5724	0.9733
Chronic heart failure (%)	1.8819	1.3928	2.5427	<0.0001
Hypertension (%)	1.4546	1.0589	1.9983	0.0202
CAD (%)	5.1507	3.8039	6.9744	<0.0001
PAD (%)	2.4907	1.7426	3.5599	<0.0001
Diabetes mellitus (%)	1.6023	1.2069	2.1270	0.0010
Type of AF (%) (ref. = first detected)	0.7389	0.5541	0.9854	0.0390
Heart rhythm strategy (%) (ref. = rhythm control only)	0.4464	0.2595	0.7677	0.0028
Zone 3: South (Greece, Italy, Portugal)
Age (%) (ref. = ≤65 years)	2.5456	1.6490	3.9297	<0.0001
Female gender (%)	0.4779	0.3319	0.6881	<0.0001
Valvular heart disease (%)	1.7361	1.1890	2.5350	0.0040
Previous TIA/stroke (%)	1.6033	0.9988	2.5739	0.0489
Chronic heart failure (%)	2.5786	1.8496	3.5949	<0.0001
Hypertension (%)	1.7333	1.1545	2.6023	0.0074
CAD (%)	19.7886	12.7869	30.6241	<0.0001
PAD (%)	2.1623	1.4587	3.2054	<0.0001
Diabetes mellitus (%)	2.0772	1.4446	2.9868	<0.0001
Type of AF (%) (ref. = first detected)	0.9548	0.6786	1.3433	0.7905
Heart rhythm strategy (%) (ref. = rhythm control only)	0.5602	0.3137	1.0005	0.0475

CAD, coronary artery disease; PAD, peripheral vascular disease.

Determinants of NOAC use in the East were previous TIA/stroke (P = 0.0108), no coronary artery disease (P = 0.0048), type of AF (P = 0.0089), and non-rhythm control (P = 0.0110). In the South, NOAC use was more common with younger age (P = 0.0002), non-valvular heart disease (P < 0.0001), no coronary artery disease (P = 0.0161), type of AF (P = 0.0489), and non-rhythm control (P = 0.0113) (Table 2).

Determinants of antiplatelet therapy use in West countries were coronary artery disease (P = 0.0014) and lack of hypertension (P = 0.0077). In East countries, older age (P = 0.0003), coronary artery disease (P = 0.0009), and type of AF (P = 0.0007) determined antiplatelet therapy use. In the South, significant factors were younger age (P = 0.0128), no previous stroke/TIA (P = 0.0398) or heart failure (P < 0.0001), and non-rhythm control (P = 0.0351) (Table 2).

Determinants of combination OAC plus antiplatelet therapy in the West were older age (P = 0.0073), hypertension (P = 0.0039), coronary artery disease (P < 0.0001), and peripheral vascular disease (P = 0.0014). In the East, combination therapy was more common in older patients (P = 0.0318), coronary artery disease (P < 0.0001), and peripheral artery disease (P < 0.0001). In the East countries, combination therapy was more common with older age (P = 0.0318), males (P = 0.0054), valvular heart disease (P < 0.0001), chronic heart failure (P < 0.0001), hypertension (P = 0.0202), coronary artery disease (P < 0.0001), peripheral artery disease (P < 0.0001), diabetes (P = 0.0010), type of AF (P = 0.0390), and non-rhythm control (P = 0.0028). In the South, determinants of combination therapy were older age (P < 0.0001), males (P < 0.0001), valvular heart disease (P = 0.004), previous stroke/TIA (P = 0.0489), chronic heart failure (P < 0.0001), hypertension (P = 0.0074), coronary artery disease (P < 0.0001) and peripheral artery disease (P < 0.0001), diabetes (P < 0.0001), and non-rhythm control (P = 0.0475) (Table 2).

Prevalence of stroke risk factors by region

Apart from age and female sex, the commonest stroke risk factors in the West countries were hypertension (57.1%) and heart failure (21.7%), and in the South countries (73.1 and 37.1%, respectively). In the East, hypertension (76.8%), heart failure (69.6%), and diabetes (23.9%) were the most common (Table 3).

Table 3

Prevalence of stroke risk factors in patients according to the ESC guidelines

	Whole cohort		OAC alone
	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Heart failure (%)	152	21.7	103	20.3
Hypertension (%)	436	57.1	323	59.6
Age (%):
<65	273	35.5	186	34.0
65–74	286	37.2	216	39.5
≥75	210	27.3	145	26.5
Diabetes mellitus (%)	117	15.2	83	15.2
Previous TIA (%)	33	4.3	28	5.2
Previous stroke (%)	43	5.6	28	5.1
Ischaemic thromboembolic complications (%)	89	11.6	62	11.4
PAD (%)	23	3.5	13	2.9
Myocardial infarction (MI) (%)	81	12.6	29	6.2
Female (%)	258	33.6	185	33.8
Zone 2: East (Poland, Romania)
Heart failure (%)	892	69.6	434	66.1
Hypertension (%)	1000	76.8	513	76.7
Age (%):
<65	482	36.9	275	41.0
65–74	441	33.8	226	33.7
≥75	383	29.3	170	25.3
Diabetes mellitus (%)	310	23.9	149	22.4
Previous TIA (%)	31	2.4	17	2.6
Previous stroke (%)	96	7.4	57	8.5
Ischaemic thromboembolic complications (%)	164	12.7	94	14.1
PAD (%)	146	11.4	51	7.7
Myocardial infarction (MI) (%)	172	15.5	41	7.4
Female (%)	594	45.5	328	48.9
Zone 3: South (Greece, Italy, Portugal)
Heart failure (%)	367	37.1	202	35.8
Hypertension (%)	758	73.1	426	73.7
Age (%)
<65	275	26.3	152	26.1
65–74	311	29.8	189	32.4
≥75	458	43.9	242	41.5
Diabetes mellitus (%)	211	20.3	101	17.4
Previous TIA (%)	62	6.0	36	6.2
Previous stroke (%)	56	5.4	35	6.0
Ischaemic thromboembolic complications (%)	152	14.6	94	16.2
PAD (%)	159	15.3	79	13.6
Myocardial infarction (MI) (%)	186	19.8	43	8.1
Female (%)	408	39.1	245	42.0

	Whole cohort		OAC alone
	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Heart failure (%)	152	21.7	103	20.3
Hypertension (%)	436	57.1	323	59.6
Age (%):
<65	273	35.5	186	34.0
65–74	286	37.2	216	39.5
≥75	210	27.3	145	26.5
Diabetes mellitus (%)	117	15.2	83	15.2
Previous TIA (%)	33	4.3	28	5.2
Previous stroke (%)	43	5.6	28	5.1
Ischaemic thromboembolic complications (%)	89	11.6	62	11.4
PAD (%)	23	3.5	13	2.9
Myocardial infarction (MI) (%)	81	12.6	29	6.2
Female (%)	258	33.6	185	33.8
Zone 2: East (Poland, Romania)
Heart failure (%)	892	69.6	434	66.1
Hypertension (%)	1000	76.8	513	76.7
Age (%):
<65	482	36.9	275	41.0
65–74	441	33.8	226	33.7
≥75	383	29.3	170	25.3
Diabetes mellitus (%)	310	23.9	149	22.4
Previous TIA (%)	31	2.4	17	2.6
Previous stroke (%)	96	7.4	57	8.5
Ischaemic thromboembolic complications (%)	164	12.7	94	14.1
PAD (%)	146	11.4	51	7.7
Myocardial infarction (MI) (%)	172	15.5	41	7.4
Female (%)	594	45.5	328	48.9
Zone 3: South (Greece, Italy, Portugal)
Heart failure (%)	367	37.1	202	35.8
Hypertension (%)	758	73.1	426	73.7
Age (%)
<65	275	26.3	152	26.1
65–74	311	29.8	189	32.4
≥75	458	43.9	242	41.5
Diabetes mellitus (%)	211	20.3	101	17.4
Previous TIA (%)	62	6.0	36	6.2
Previous stroke (%)	56	5.4	35	6.0
Ischaemic thromboembolic complications (%)	152	14.6	94	16.2
PAD (%)	159	15.3	79	13.6
Myocardial infarction (MI) (%)	186	19.8	43	8.1
Female (%)	408	39.1	245	42.0

PAD, peripheral vascular disease.

Table 3

Prevalence of stroke risk factors in patients according to the ESC guidelines

	Whole cohort		OAC alone
	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Heart failure (%)	152	21.7	103	20.3
Hypertension (%)	436	57.1	323	59.6
Age (%):
<65	273	35.5	186	34.0
65–74	286	37.2	216	39.5
≥75	210	27.3	145	26.5
Diabetes mellitus (%)	117	15.2	83	15.2
Previous TIA (%)	33	4.3	28	5.2
Previous stroke (%)	43	5.6	28	5.1
Ischaemic thromboembolic complications (%)	89	11.6	62	11.4
PAD (%)	23	3.5	13	2.9
Myocardial infarction (MI) (%)	81	12.6	29	6.2
Female (%)	258	33.6	185	33.8
Zone 2: East (Poland, Romania)
Heart failure (%)	892	69.6	434	66.1
Hypertension (%)	1000	76.8	513	76.7
Age (%):
<65	482	36.9	275	41.0
65–74	441	33.8	226	33.7
≥75	383	29.3	170	25.3
Diabetes mellitus (%)	310	23.9	149	22.4
Previous TIA (%)	31	2.4	17	2.6
Previous stroke (%)	96	7.4	57	8.5
Ischaemic thromboembolic complications (%)	164	12.7	94	14.1
PAD (%)	146	11.4	51	7.7
Myocardial infarction (MI) (%)	172	15.5	41	7.4
Female (%)	594	45.5	328	48.9
Zone 3: South (Greece, Italy, Portugal)
Heart failure (%)	367	37.1	202	35.8
Hypertension (%)	758	73.1	426	73.7
Age (%)
<65	275	26.3	152	26.1
65–74	311	29.8	189	32.4
≥75	458	43.9	242	41.5
Diabetes mellitus (%)	211	20.3	101	17.4
Previous TIA (%)	62	6.0	36	6.2
Previous stroke (%)	56	5.4	35	6.0
Ischaemic thromboembolic complications (%)	152	14.6	94	16.2
PAD (%)	159	15.3	79	13.6
Myocardial infarction (MI) (%)	186	19.8	43	8.1
Female (%)	408	39.1	245	42.0

	Whole cohort		OAC alone
	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
Heart failure (%)	152	21.7	103	20.3
Hypertension (%)	436	57.1	323	59.6
Age (%):
<65	273	35.5	186	34.0
65–74	286	37.2	216	39.5
≥75	210	27.3	145	26.5
Diabetes mellitus (%)	117	15.2	83	15.2
Previous TIA (%)	33	4.3	28	5.2
Previous stroke (%)	43	5.6	28	5.1
Ischaemic thromboembolic complications (%)	89	11.6	62	11.4
PAD (%)	23	3.5	13	2.9
Myocardial infarction (MI) (%)	81	12.6	29	6.2
Female (%)	258	33.6	185	33.8
Zone 2: East (Poland, Romania)
Heart failure (%)	892	69.6	434	66.1
Hypertension (%)	1000	76.8	513	76.7
Age (%):
<65	482	36.9	275	41.0
65–74	441	33.8	226	33.7
≥75	383	29.3	170	25.3
Diabetes mellitus (%)	310	23.9	149	22.4
Previous TIA (%)	31	2.4	17	2.6
Previous stroke (%)	96	7.4	57	8.5
Ischaemic thromboembolic complications (%)	164	12.7	94	14.1
PAD (%)	146	11.4	51	7.7
Myocardial infarction (MI) (%)	172	15.5	41	7.4
Female (%)	594	45.5	328	48.9
Zone 3: South (Greece, Italy, Portugal)
Heart failure (%)	367	37.1	202	35.8
Hypertension (%)	758	73.1	426	73.7
Age (%)
<65	275	26.3	152	26.1
65–74	311	29.8	189	32.4
≥75	458	43.9	242	41.5
Diabetes mellitus (%)	211	20.3	101	17.4
Previous TIA (%)	62	6.0	36	6.2
Previous stroke (%)	56	5.4	35	6.0
Ischaemic thromboembolic complications (%)	152	14.6	94	16.2
PAD (%)	159	15.3	79	13.6
Myocardial infarction (MI) (%)	186	19.8	43	8.1
Female (%)	408	39.1	245	42.0

PAD, peripheral vascular disease.

Antithrombotic therapy use with cardioversion and ablation

Among those patients in whom PCV was performed, OAC (or OAC plus antiplatelet therapy) was used in 80.6% in the West countries, compared with 71.6% in the East and 50.0% in the South countries (Table 4).

Table 4

Antithrombotic prescription at inclusion and at discharge when PCV was either performed at the time of the survey or planned at discharge

	Performed (n = 93)				Planned (n = 5)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	20	21.5	8	8.6	0	0.0	0	0.0
OAC alone	49	52.7	59	63.4	4	80.0	5	100.0
Antiplatelet alone	14	15.1	6	6.5	1	20.0	0	0.0
OAC + antiplatelet	8	8.6	16	17.2	0	0.0	0	0.0
Others^a	2	2.1	4	4.3	0	0.0	0	0.0
Total	93	100.0	93	100.0	5	100.0	5	100.0
	Performed (n = 447)				Planned (n = 6)
Zone 2: East (Poland, Romania)
None and unknown	188	42.0	25	5.6	1	16.6	0	0.0
OAC alone	86	19.2	145	32.4	3	50.0	3	50.0
Antiplatelet alone	125	28.0	88	19.7	1	16.7	0	0.0
OAC + antiplatelet	41	9.2	175	39.2	1	16.7	2	33.3
Others^a	7	1.6	14	3.1	0	0.0	1	16.7
Total	447	100.0	447	100.0	6	100.0	6	100.0
	Performed (n = 210)				Planned (n = 2)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	78	37.1	35	16.7	1	50.0	0	0.0
OAC alone	53	25.2	76	36.2	1	50.0	1	50.0
Antiplatelet alone	51	24.3	53	25.2	0	0.0	0	0.0
OAC + antiplatelet	17	8.1	29	13.8	0	0.0	1	50.0
Others^a	11	5.2	17	8.1	0	0.0	0	0.0
Total	210	100.0	210	100.0	2	100.0	2	100.0

	Performed (n = 93)				Planned (n = 5)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	20	21.5	8	8.6	0	0.0	0	0.0
OAC alone	49	52.7	59	63.4	4	80.0	5	100.0
Antiplatelet alone	14	15.1	6	6.5	1	20.0	0	0.0
OAC + antiplatelet	8	8.6	16	17.2	0	0.0	0	0.0
Others^a	2	2.1	4	4.3	0	0.0	0	0.0
Total	93	100.0	93	100.0	5	100.0	5	100.0
	Performed (n = 447)				Planned (n = 6)
Zone 2: East (Poland, Romania)
None and unknown	188	42.0	25	5.6	1	16.6	0	0.0
OAC alone	86	19.2	145	32.4	3	50.0	3	50.0
Antiplatelet alone	125	28.0	88	19.7	1	16.7	0	0.0
OAC + antiplatelet	41	9.2	175	39.2	1	16.7	2	33.3
Others^a	7	1.6	14	3.1	0	0.0	1	16.7
Total	447	100.0	447	100.0	6	100.0	6	100.0
	Performed (n = 210)				Planned (n = 2)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	78	37.1	35	16.7	1	50.0	0	0.0
OAC alone	53	25.2	76	36.2	1	50.0	1	50.0
Antiplatelet alone	51	24.3	53	25.2	0	0.0	0	0.0
OAC + antiplatelet	17	8.1	29	13.8	0	0.0	1	50.0
Others^a	11	5.2	17	8.1	0	0.0	0	0.0
Total	210	100.0	210	100.0	2	100.0	2	100.0

^aOthers include: OAC + Other ATT, AP + Other ATT, OAC + AP + Other ATT and Other ATT (fondaparinux, LMW heparin, UF heparin, other).

Table 4

Antithrombotic prescription at inclusion and at discharge when PCV was either performed at the time of the survey or planned at discharge

	Performed (n = 93)				Planned (n = 5)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	20	21.5	8	8.6	0	0.0	0	0.0
OAC alone	49	52.7	59	63.4	4	80.0	5	100.0
Antiplatelet alone	14	15.1	6	6.5	1	20.0	0	0.0
OAC + antiplatelet	8	8.6	16	17.2	0	0.0	0	0.0
Others^a	2	2.1	4	4.3	0	0.0	0	0.0
Total	93	100.0	93	100.0	5	100.0	5	100.0
	Performed (n = 447)				Planned (n = 6)
Zone 2: East (Poland, Romania)
None and unknown	188	42.0	25	5.6	1	16.6	0	0.0
OAC alone	86	19.2	145	32.4	3	50.0	3	50.0
Antiplatelet alone	125	28.0	88	19.7	1	16.7	0	0.0
OAC + antiplatelet	41	9.2	175	39.2	1	16.7	2	33.3
Others^a	7	1.6	14	3.1	0	0.0	1	16.7
Total	447	100.0	447	100.0	6	100.0	6	100.0
	Performed (n = 210)				Planned (n = 2)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	78	37.1	35	16.7	1	50.0	0	0.0
OAC alone	53	25.2	76	36.2	1	50.0	1	50.0
Antiplatelet alone	51	24.3	53	25.2	0	0.0	0	0.0
OAC + antiplatelet	17	8.1	29	13.8	0	0.0	1	50.0
Others^a	11	5.2	17	8.1	0	0.0	0	0.0
Total	210	100.0	210	100.0	2	100.0	2	100.0

	Performed (n = 93)				Planned (n = 5)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	20	21.5	8	8.6	0	0.0	0	0.0
OAC alone	49	52.7	59	63.4	4	80.0	5	100.0
Antiplatelet alone	14	15.1	6	6.5	1	20.0	0	0.0
OAC + antiplatelet	8	8.6	16	17.2	0	0.0	0	0.0
Others^a	2	2.1	4	4.3	0	0.0	0	0.0
Total	93	100.0	93	100.0	5	100.0	5	100.0
	Performed (n = 447)				Planned (n = 6)
Zone 2: East (Poland, Romania)
None and unknown	188	42.0	25	5.6	1	16.6	0	0.0
OAC alone	86	19.2	145	32.4	3	50.0	3	50.0
Antiplatelet alone	125	28.0	88	19.7	1	16.7	0	0.0
OAC + antiplatelet	41	9.2	175	39.2	1	16.7	2	33.3
Others^a	7	1.6	14	3.1	0	0.0	1	16.7
Total	447	100.0	447	100.0	6	100.0	6	100.0
	Performed (n = 210)				Planned (n = 2)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	78	37.1	35	16.7	1	50.0	0	0.0
OAC alone	53	25.2	76	36.2	1	50.0	1	50.0
Antiplatelet alone	51	24.3	53	25.2	0	0.0	0	0.0
OAC + antiplatelet	17	8.1	29	13.8	0	0.0	1	50.0
Others^a	11	5.2	17	8.1	0	0.0	0	0.0
Total	210	100.0	210	100.0	2	100.0	2	100.0

^aOthers include: OAC + Other ATT, AP + Other ATT, OAC + AP + Other ATT and Other ATT (fondaparinux, LMW heparin, UF heparin, other).

For ECV, the corresponding figures were 87.0, 88.2, and 81.6%, respectively (Table 5). For the patients undergoing ablation, the corresponding figures by region were 94.2, 76.2, and 87.9%, respectively (Table 6).

Table 5

Antithrombotic prescription at inclusion and at discharge when ECV were either performed at the time of the survey or planned at discharge

	Performed (n = 253)				Planned (n = 48)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and Unknown	20	7.9	9	3.5	13	27.1	1	2.1
OAC alone	183	72.3	188	74.3	20	41.7	37	77.1
Antiplatelet alone	15	5.9	11	4.4	10	20.8	0	0.0
OAC + antiplatelet	31	12.3	32	12.7	4	8.3	5	10.4
Others^a	4	1.6	13	5.1	1	2.1	5	10.4
Total	253	100.0	253	100.0	48	100.0	48	100.0
	Performed (n = 153)				Planned (n = 19)
Zone 2: East (Poland, Romania)
None and Unknown	16	10.4	3	2.0	6	31.6	0	0.0
OAC alone	100	65.4	109	71.2	7	36.8	17	89.4
Antiplatelet alone	12	7.8	8	5.2	5	26.3	0	0.0
OAC + antiplatelet	24	15.7	26	17.0	1	5.3	1	5.3
Others^a	1	0.7	7	4.6	0	0.0	1	5.3
Total	153	100.0	153	100.0	19	100.0	19	100.0
	Performed (n = 206)				Planned (n = 24)
Zone 3: South (Greece, Italy, Portugal)
None and Unknown	28	13.6	11	5.3	4	16.7	0	0.0
OAC alone	123	59.7	133	64.6	14	58.3	20	83.3
Antiplatelet Alone	18	8.7	18	8.7	4	16.7	0	0.0
OAC + antiplatelet	30	14.6	35	17.0	1	4.2	2	8.3
Others^a	7	3.4	9	4.4	1	4.2	2	8.3
Total	206	100.0	206	100.0	24	100.0	24	100.0

	Performed (n = 253)				Planned (n = 48)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and Unknown	20	7.9	9	3.5	13	27.1	1	2.1
OAC alone	183	72.3	188	74.3	20	41.7	37	77.1
Antiplatelet alone	15	5.9	11	4.4	10	20.8	0	0.0
OAC + antiplatelet	31	12.3	32	12.7	4	8.3	5	10.4
Others^a	4	1.6	13	5.1	1	2.1	5	10.4
Total	253	100.0	253	100.0	48	100.0	48	100.0
	Performed (n = 153)				Planned (n = 19)
Zone 2: East (Poland, Romania)
None and Unknown	16	10.4	3	2.0	6	31.6	0	0.0
OAC alone	100	65.4	109	71.2	7	36.8	17	89.4
Antiplatelet alone	12	7.8	8	5.2	5	26.3	0	0.0
OAC + antiplatelet	24	15.7	26	17.0	1	5.3	1	5.3
Others^a	1	0.7	7	4.6	0	0.0	1	5.3
Total	153	100.0	153	100.0	19	100.0	19	100.0
	Performed (n = 206)				Planned (n = 24)
Zone 3: South (Greece, Italy, Portugal)
None and Unknown	28	13.6	11	5.3	4	16.7	0	0.0
OAC alone	123	59.7	133	64.6	14	58.3	20	83.3
Antiplatelet Alone	18	8.7	18	8.7	4	16.7	0	0.0
OAC + antiplatelet	30	14.6	35	17.0	1	4.2	2	8.3
Others^a	7	3.4	9	4.4	1	4.2	2	8.3
Total	206	100.0	206	100.0	24	100.0	24	100.0

^aOthers include: OAC + other ATT, AP + other ATT, OAC + AP + other ATT and other ATT (fondaparinux, LMWheparin, UFheparin, other).

Table 5

Antithrombotic prescription at inclusion and at discharge when ECV were either performed at the time of the survey or planned at discharge

	Performed (n = 253)				Planned (n = 48)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and Unknown	20	7.9	9	3.5	13	27.1	1	2.1
OAC alone	183	72.3	188	74.3	20	41.7	37	77.1
Antiplatelet alone	15	5.9	11	4.4	10	20.8	0	0.0
OAC + antiplatelet	31	12.3	32	12.7	4	8.3	5	10.4
Others^a	4	1.6	13	5.1	1	2.1	5	10.4
Total	253	100.0	253	100.0	48	100.0	48	100.0
	Performed (n = 153)				Planned (n = 19)
Zone 2: East (Poland, Romania)
None and Unknown	16	10.4	3	2.0	6	31.6	0	0.0
OAC alone	100	65.4	109	71.2	7	36.8	17	89.4
Antiplatelet alone	12	7.8	8	5.2	5	26.3	0	0.0
OAC + antiplatelet	24	15.7	26	17.0	1	5.3	1	5.3
Others^a	1	0.7	7	4.6	0	0.0	1	5.3
Total	153	100.0	153	100.0	19	100.0	19	100.0
	Performed (n = 206)				Planned (n = 24)
Zone 3: South (Greece, Italy, Portugal)
None and Unknown	28	13.6	11	5.3	4	16.7	0	0.0
OAC alone	123	59.7	133	64.6	14	58.3	20	83.3
Antiplatelet Alone	18	8.7	18	8.7	4	16.7	0	0.0
OAC + antiplatelet	30	14.6	35	17.0	1	4.2	2	8.3
Others^a	7	3.4	9	4.4	1	4.2	2	8.3
Total	206	100.0	206	100.0	24	100.0	24	100.0

	Performed (n = 253)				Planned (n = 48)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and Unknown	20	7.9	9	3.5	13	27.1	1	2.1
OAC alone	183	72.3	188	74.3	20	41.7	37	77.1
Antiplatelet alone	15	5.9	11	4.4	10	20.8	0	0.0
OAC + antiplatelet	31	12.3	32	12.7	4	8.3	5	10.4
Others^a	4	1.6	13	5.1	1	2.1	5	10.4
Total	253	100.0	253	100.0	48	100.0	48	100.0
	Performed (n = 153)				Planned (n = 19)
Zone 2: East (Poland, Romania)
None and Unknown	16	10.4	3	2.0	6	31.6	0	0.0
OAC alone	100	65.4	109	71.2	7	36.8	17	89.4
Antiplatelet alone	12	7.8	8	5.2	5	26.3	0	0.0
OAC + antiplatelet	24	15.7	26	17.0	1	5.3	1	5.3
Others^a	1	0.7	7	4.6	0	0.0	1	5.3
Total	153	100.0	153	100.0	19	100.0	19	100.0
	Performed (n = 206)				Planned (n = 24)
Zone 3: South (Greece, Italy, Portugal)
None and Unknown	28	13.6	11	5.3	4	16.7	0	0.0
OAC alone	123	59.7	133	64.6	14	58.3	20	83.3
Antiplatelet Alone	18	8.7	18	8.7	4	16.7	0	0.0
OAC + antiplatelet	30	14.6	35	17.0	1	4.2	2	8.3
Others^a	7	3.4	9	4.4	1	4.2	2	8.3
Total	206	100.0	206	100.0	24	100.0	24	100.0

^aOthers include: OAC + other ATT, AP + other ATT, OAC + AP + other ATT and other ATT (fondaparinux, LMWheparin, UFheparin, other).

Table 6

Antithrombotic prescription at inclusion and at discharge when the following catheter ablation was either performed at the time of the survey or planned at discharge

	Performed (n = 86)				Planned (n = 22)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	0	0.0	3	3.4	2	9.1	0	0.0
OAC alone	76	88.4	75	87.2	16	72.7	18	81.8
Antiplatelet alone	2	2.3	1	1.2	0	0.0	0	0.0
OAC + antiplatelet	7	8.1	6	7.0	2	9.1	2	9.1
Others^a	1	1.2	1	1.2	2	9.1	2	9.1
Total	86	100.0	86	100.0	22	100.0	22	100.0
	Performed (n = 42)				Planned (n = 12)
Zone 2: East (Poland, Romania)
None and unknown	1	2.4	0	0.0	1	8.3	0	0.0
OAC alone	34	81.0	30	71.4	7	58.3	2	16.7
Antiplatelet alone	1	2.4	3	7.1	0	0.0	1	8.3
OAC + antiplatelet	1	2.4	2	4.8	3	25.0	3	25.0
Others^a	5	11.8	7	16.7	1	8.4	6	50.0
Total	42	100.0	42	100.0	12	100.0	12	100.0
	Performed (n = 58)				Planned (n = 11)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	2	3.5	2	3.5	2	18.2	2	18.2
OAC alone	49	84.5	50	86.2	7	63.6	8	72.7
Antiplatelet alone	7	12.1	5	8.6	2	18.2	1	9.1
OAC + antiplatelet	0	0.0	1	1.7	0	0.0	0	0.0
Others^a	0	0.0	0	0.0	0	0.0	0	0.0
Total	58	100.0	58	100.0	11	100.0	11	100.0

	Performed (n = 86)				Planned (n = 22)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	0	0.0	3	3.4	2	9.1	0	0.0
OAC alone	76	88.4	75	87.2	16	72.7	18	81.8
Antiplatelet alone	2	2.3	1	1.2	0	0.0	0	0.0
OAC + antiplatelet	7	8.1	6	7.0	2	9.1	2	9.1
Others^a	1	1.2	1	1.2	2	9.1	2	9.1
Total	86	100.0	86	100.0	22	100.0	22	100.0
	Performed (n = 42)				Planned (n = 12)
Zone 2: East (Poland, Romania)
None and unknown	1	2.4	0	0.0	1	8.3	0	0.0
OAC alone	34	81.0	30	71.4	7	58.3	2	16.7
Antiplatelet alone	1	2.4	3	7.1	0	0.0	1	8.3
OAC + antiplatelet	1	2.4	2	4.8	3	25.0	3	25.0
Others^a	5	11.8	7	16.7	1	8.4	6	50.0
Total	42	100.0	42	100.0	12	100.0	12	100.0
	Performed (n = 58)				Planned (n = 11)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	2	3.5	2	3.5	2	18.2	2	18.2
OAC alone	49	84.5	50	86.2	7	63.6	8	72.7
Antiplatelet alone	7	12.1	5	8.6	2	18.2	1	9.1
OAC + antiplatelet	0	0.0	1	1.7	0	0.0	0	0.0
Others^a	0	0.0	0	0.0	0	0.0	0	0.0
Total	58	100.0	58	100.0	11	100.0	11	100.0

^aOthers include: OAC + other ATT, AP + other ATT, OAC + AP + other ATT and other ATT (fondaparinux, LMW heparin, UF heparin, other).

Table 6

Antithrombotic prescription at inclusion and at discharge when the following catheter ablation was either performed at the time of the survey or planned at discharge

	Performed (n = 86)				Planned (n = 22)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	0	0.0	3	3.4	2	9.1	0	0.0
OAC alone	76	88.4	75	87.2	16	72.7	18	81.8
Antiplatelet alone	2	2.3	1	1.2	0	0.0	0	0.0
OAC + antiplatelet	7	8.1	6	7.0	2	9.1	2	9.1
Others^a	1	1.2	1	1.2	2	9.1	2	9.1
Total	86	100.0	86	100.0	22	100.0	22	100.0
	Performed (n = 42)				Planned (n = 12)
Zone 2: East (Poland, Romania)
None and unknown	1	2.4	0	0.0	1	8.3	0	0.0
OAC alone	34	81.0	30	71.4	7	58.3	2	16.7
Antiplatelet alone	1	2.4	3	7.1	0	0.0	1	8.3
OAC + antiplatelet	1	2.4	2	4.8	3	25.0	3	25.0
Others^a	5	11.8	7	16.7	1	8.4	6	50.0
Total	42	100.0	42	100.0	12	100.0	12	100.0
	Performed (n = 58)				Planned (n = 11)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	2	3.5	2	3.5	2	18.2	2	18.2
OAC alone	49	84.5	50	86.2	7	63.6	8	72.7
Antiplatelet alone	7	12.1	5	8.6	2	18.2	1	9.1
OAC + antiplatelet	0	0.0	1	1.7	0	0.0	0	0.0
Others^a	0	0.0	0	0.0	0	0.0	0	0.0
Total	58	100.0	58	100.0	11	100.0	11	100.0

	Performed (n = 86)				Planned (n = 22)
	Inclusion		Discharge		Inclusion		Discharge
	N	%	N	%	N	%	N	%
Zone 1: West (Belgium, Denmark, Netherlands, Norway)
None and unknown	0	0.0	3	3.4	2	9.1	0	0.0
OAC alone	76	88.4	75	87.2	16	72.7	18	81.8
Antiplatelet alone	2	2.3	1	1.2	0	0.0	0	0.0
OAC + antiplatelet	7	8.1	6	7.0	2	9.1	2	9.1
Others^a	1	1.2	1	1.2	2	9.1	2	9.1
Total	86	100.0	86	100.0	22	100.0	22	100.0
	Performed (n = 42)				Planned (n = 12)
Zone 2: East (Poland, Romania)
None and unknown	1	2.4	0	0.0	1	8.3	0	0.0
OAC alone	34	81.0	30	71.4	7	58.3	2	16.7
Antiplatelet alone	1	2.4	3	7.1	0	0.0	1	8.3
OAC + antiplatelet	1	2.4	2	4.8	3	25.0	3	25.0
Others^a	5	11.8	7	16.7	1	8.4	6	50.0
Total	42	100.0	42	100.0	12	100.0	12	100.0
	Performed (n = 58)				Planned (n = 11)
Zone 3: South (Greece, Italy, Portugal)
None and unknown	2	3.5	2	3.5	2	18.2	2	18.2
OAC alone	49	84.5	50	86.2	7	63.6	8	72.7
Antiplatelet alone	7	12.1	5	8.6	2	18.2	1	9.1
OAC + antiplatelet	0	0.0	1	1.7	0	0.0	0	0.0
Others^a	0	0.0	0	0.0	0	0.0	0	0.0
Total	58	100.0	58	100.0	11	100.0	11	100.0

^aOthers include: OAC + other ATT, AP + other ATT, OAC + AP + other ATT and other ATT (fondaparinux, LMW heparin, UF heparin, other).

Characteristics of patients undergoing cardioversion and ablation

The median ages of those undergoing PCV, ECV, and ablation in West countries were 69, 67, and 63 years, respectively. In East countries, the corresponding figures were 69, 60, and 59, respectively. In the South, median ages were 69, 70, and 59.5, respectively.

In West countries, duration of AF > 7 days among those undergoing PCV, ECV, and ablation were 17.2, 39.9, and 20.9%. The corresponding percentages in East countries were 38.9, 64.7, and 40.5%, respectively. In the South, the corresponding figures were 9.1, 46.6, and 22.4%, respectively (Supplementary material online, Table S1).

The proportions with a CHA₂DS₂-VASc score of ≥2 in West countries were 68.8, 62.1, and 57.0%, respectively. In East countries, the corresponding figures were 90.1, 74.5, and 35.7%, while in South countries, 72.4, 76.2, and 44.8%, respectively.

Discussion

In this analysis from the EORP-AF Pilot registry, we show regional differences in patient characteristics, treatment options, and management options among European cardiologists. In particular, stroke risk and application of antithrombotic therapy varied, as did patient selection for rhythm control interventions. This is despite publication of new guidelines from the ESC in 2010, which was followed by a focused update in 2012.^4,5

As expected, heart failure was the commonest cause for hospitalization in all regions. Chronic heart failure was particularly common in East countries, and the combination of AF and heart failure (especially those requiring hospitalization) leads to a poor prognosis.¹² Our dataset does not differentiate between heart failure with reduced or preserved ejection fraction (HFrEF and HFpEF, respectively) but recent studies suggest that irrespective of ejection fraction, decompensated heart failure is associated with more adverse outcomes in the presence of AF.^13–15

Differences in associated comorbidity were evident. Of note, hypertension, peripheral artery disease and chronic kidney disease were more common in South countries, where patients were significantly older. This is in keeping with the high disease burden associated with hypertension in South countries.¹⁶ These comorbidities contribute to increased cardiovascular risk associated with AF, particularly from thromboembolism.¹⁷

Stroke risk as quantified by a CHA₂DS₂-VASc score of ≥2 was generally highest in East and South countries. OAC use was generally high (>72%) but antiplatelet therapy is still used in ∼15%. Indeed, differences in determinants of antithrombotic therapy use were evident, particularly where antiplatelet therapy was used alone or in combination with OAC. Coronary artery disease was a very strong determinant of antiplatelet therapy use, whether alone or in combination with OAC. Combination of OAC plus antiplatelet therapy use was also more common with older age, male sex, peripheral artery disease and especially in the South, where concomitant stroke risk factors were evident. This is despite evidence that in patients with stable vascular disease, combination OAC plus antiplatelet therapy does not confer added advantage in reducing stroke and thromboembolism, but substantially increases the risk of major bleeding, especially intracranial bleeding.^18–20

OAC in patients selected for rhythm control was highest in West countries, compared with only 50% use among those who had undergone PCV in South countries. This is surprising, as cardioversion of patients with AF of >48 h duration—whether electrical or pharmacological—should require appropriate thromboprophylaxis.⁴ This is consistent with a recent registry (RHYTHM-AF) showing substantial variation in management, and undertreatment with antithrombotic therapy in patients undergoing cardioversion.^11,21

Interestingly, patients from West countries undergoing ECV were younger, while AF duration in South countries of patients undergoing rhythm control was usually <7 days. Such patients probably have the better chance of a successful outcome. Patients from East countries undergoing pharmacological or ECV were generally at higher stroke risk (as evident by the proportion with a CHA₂DS₂-VASc score of ≥2), while those undergoing ablation in East countries had the lowest stroke risk (CHA₂DS₂-VASc score of ≥2 in only 35.7%). The high stroke risk profile in those undergoing cardioversion is perhaps surprising, as multiple comorbidities (reflected by a high CHA₂DS₂-VASc score) may reduce the chance of successful outcomes with rhythm control and the long-term maintenance of sinus rhythm.²² The best evidence for ablation success is in those with few comorbidities, and practice in East countries reflects this, while West and South countries perform ablation on high stroke risk patients.²³ Current guidelines recommend that OAC should not be stopped post-ablation in patients with a CHA₂DS₂-VASc score of ≥2.^4,23

Limitations

This pilot registry is limited by its dependence upon data obtained from the cardiologists in nine ESC member countries only, and we recognize that in many healthcare systems, AF patients are often looked after by non-cardiologists. Nonetheless, this analysis provides evidence for regional differences in patient characteristics, treatment options and management options. Our division into three regions (West, East, and South) is also an artificial division of convenience, and inter-country differences would also be evident. Nonetheless, it is recognized that geographic variations can lack statistical power, and are at besthypothesis-generating.²⁴ Random effects may be of importance, for example, higher comorbidities in ‘East’ countries which could plausibly lead to less rhythm control strategies in these countries. Also, an analysis by country would be interesting but we would be underpowered due to the modest numbers per country if such an analysis was made. Indeed, some of the management practices may also reflect the choice of participating centres, but the EORP-AF protocol includes consecutive patients and obtains a mix of electrophysiology- and non-electrophysiology-based hospitals to reflect representative clinical practice in the various countries. Nonetheless, we have avoided comparisons of management in relation to the type of clinical practice (e.g. office vs. hospital-based cardiologists) in one country vs. another, as we may not be comparing like with like; however, we have tried to minimize heterogeneity by focusing on the subgroup of n = 902 hospital-admitted patients in whom no rhythm control was performed or planned at initial presentation. The relatively small numbers in some subgroups, for example, in determining antithrombotic therapy use, are a limitation and it remains possible that with larger numbers more homogeneity may be evident. We also recognize that regional descriptions of the rhythm control patients are based on small numbers. Finally, the present analysis focuses on baseline data, and outcome data from the EORP-AF Pilot registry follow-up phase will become available in due course. A more comprehensive assessment in all member ESC countries would be obtained from the EORP-AF general long-term registry.

Conclusions

From the systematic collection of contemporary data regarding the management and treatment of AF in nine participating member ESC countries, we provide hypothesis-generating observational insights into regional management practices in Europe with regard to patient characteristics and treatment options.

Supplementary material

Supplementary material is available at Europace online.

EORP sponsors

At the time of the registry, the following companies are supporting the EURObservational Research programme: GOLD: Abott Vascular, Bayer Pharma, Bristol Myers Squibb (BMS), Pfizer, Boehringer Ingelheim, Daiichi Sankyo Europe, Menarini international Operations, Novartis Pharma, Sanofi-Aventis, Servier International. SILVER: Amgen. BRONZE: Boston Scientific International, Merck & Co. (MSD).

Conflict of interest: G.Y.H.L.—consultant for Bayer, Medtronic, Sanoﬁ, BMS/Pfizer, Daiichi-Sankyo, and Boehringer Ingelheim, and has been a speaker for Bayer, BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo and Medtronic. L.H.R.—speaker bureaus for Bayer, BMS/Pfizer, Janssen Pharmaceuticals, Takeda, Roche Diagnostics, and Boehringer Ingelheim. G.B.—received small speaker's fee from Medtronic Inc and Boston Scientific. M.M.O.—consultant for Medtronic, Sorin, and Biotronik, and speaker bureau for Boston Scientific and St Jude Medical. L.T.: consultant and Speakers bureau member for Servier; Committee Member for Servier, Medtronic, St Jude Medical, CVIE Therapeutics, Boston Scientific, Vifor Pharma, Cardiorentis. Other authors—none declared in relation to this manuscript.

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Article Contents

Regional differences in presentation and treatment of patients with atrial fibrillation in Europe: a report from the EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry

Introduction

Methods

Statistical analyses

Results

Determinants of antithrombotic therapy use by region

Prevalence of stroke risk factors by region

Antithrombotic therapy use with cardioversion and ablation

Characteristics of patients undergoing cardioversion and ablation

Discussion

Limitations

Conclusions

Supplementary material

EORP sponsors

References

Citations

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Article Contents

Regional differences in presentation and treatment of patients with atrial fibrillation in Europe: a report from the EURObservational Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry

Introduction

Methods

Statistical analyses

Results

Determinants of antithrombotic therapy use by region

Prevalence of stroke risk factors by region

Antithrombotic therapy use with cardioversion and ablation

Characteristics of patients undergoing cardioversion and ablation

Discussion

Limitations

Conclusions

Supplementary material

EORP sponsors

References

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