Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Hábitos alimentares, infecção natural e distribuição de triotomíneos domiciliados na região nordeste do Brasil Feeding habits, natural infection and distribution of domiciliary Triatominae bugs Northeast of Brazil

São apresentadas as informações obtidas no inquérito triatomíneo levado a efeito na região nordeste do Brasil. As características biogeográficas incluem a presença de áreas semi-áridas da caatinga e amplas faixas transicionais com outras feições paisagísticas. Entre estas foram incluídas as da floresta tropical atlântica e as inclusões florestadas mais extensas. No período de 1975 a 1980 foram examinados 15.342 triotomíneos coletados no ambiente domiciliar, visando detectar as presenças de sangue ingerido e de infecção natural por Trypanosoma tipo cruzi. O conteúdo intestinal foi submetido a reações com antisoros para homem, cão, gato, roedor (Kattus), marsupial (Didelphis) e ave (Gallus). Por ordem de freqüência, as espécies encontradas foram Triatoma pseudomaculada (40,6%), Panstrongylus megistus (19,7%), Triatoma brasiliensis e T. sordida (ambos com 14,3%), Rhodnius nasutus (6,1%) e Triatoma infestans (1,1%); além de em algumas outras raras. A presença de sangue foi detectada em 42,4% e a infecção em 3,4% desse total de espécimens examinados. Observou-se elevada mobilidade alimentar, com coeficientes gerais de 54,8% para ave e 30,0% para homem. Em nível específico pôde determinar apreciável grau de antropofilia em P. megistus e, em menor intensidade, em T. brasiliensis. Por sua vez, T. infestans mostrou-se altamente antropófilo. Observou-se apreciável ornitofilia em T. pseudomaculata e T. sordida, com elevada intensidade em R. nasutus. Por outro lado, a presença de sangue humano em espécimens capturados no peridomicílio indicou a ocorrência de freqüente mobilidade espacial, com exceção de T. infestans que não mostrou evidências de abandonar o domicílio. A tendência à domiciliação, além desta, revelou-se apreciável em P. megistus, moderada em T. brasiliensi, T. pseudomaculata, T. sordida e praticamente nula em R. nasutus. A distribuição geográfica confirmou o caráter autóctone de T. brasiliensis, T. pseudomaculata e R. nasutus em relação à caatinga, e do P. megistus em relação às regiões florestais atlânticas e de inclusão. Este último revelou caráter invasivo no que concerne à caatinga, enquanto T. infestans e T. sordida mostraram o mesmo aspecto quanto à região nordeste como um todo. Os resultados permitem concluir que, na transmissão regional epidemiologicamente significante da tripanossomíase americana, desempenha papel relevante o P. megistus, em primeiro lugar, e o T. brasiliensis, em segundo. Dependendo de fatores vários, provavelmente da densidade, poderão atuar secundariamente nesse sentido o T. pseudomaculata e o T. sordida. Quanto à T. infestans, a sua presença, em número reduzido, representa, no momento, risco apenas potencial. O controle rotineiro, mediante a desinsetização domiciliar, deverá fornecer bons resultados no que concerne à interrupção da transmissão. Todavia a reinfestação, pelo menos do peridomicílio, deverá provavelmente continuar. E isso em virtude de focos extradomiciliares que fornecem espécimens com tendência à colonização no ambiente humano. É de se prever que ela se fará a custa do P. megistus nas áreas florestais atlânticas e de inclusão e de T. brasiliensis, T. pseudomaculata e R. nasutus nas áreas da caatinga. A vigilância epidemiológica deverá pois levar em conta esses aspectos e tender a aumentar sua eficiência pela continuidade das pesquisas.<br>This is the presentation of data obtained by a study carried out in the Northeast of Brazil, where the biogeographical characteristics include the "caatinga" (a semi-arid) savanna and ample transitional strips with other features. Among them are the Atlantic tropical forest and the larger forest inclusions. From 1975 to 1980, a total of 15,342 bugs collected in domiciliar environment were examined to discover the blood feeding habits of and natural infection by Trypanosoma of the cruzi type. Intestinal content was submitted to reactions to antiserums for humans, dogs, cats, rodents (Rattus), opossums (Didelphis), and birds (Gallus). By order of frequency, the species found were: Triatoma pseudomaculata (40.6%). Panstrongylus magistus (19.7%), Triatoma brasiliensis and T. sordida (14.3% each), Rhodnius nasutus (6.1%) and Triatoma infestans (1.1%), and some other rare ones. Blood was detected in 42.4% and the infection rate was 3.4% of the total of the specimens examined. High feeding mobility was observed, and the general blood containing rates were 54.8% for birds and 30.0% for humans. P. megistus showed considerable anthropophily and was followed, at a lower degree, by Triatoma brasiliensis. Ornitophily was detected at high level among T. pseudomaculata and T. sordida, while R. nasutus fed almost exclusively on this host. On the other hand, the presence of human blood in specimens collected in peridomiciliar dwelling places indicates frequent spacial mobility, which occurs after the bugs have had their blood meals. This was quite evident among all the species except T. infestans which thus showed no tedency for displacement from this environment. Domiciliarity was also evident among P. megistus and, to a lower degree, among T. brasiliensis, T. pseudomaculata and T. sordida. However, domiciliarity was not characteristics of R. nasutus. Information on geographical distribution confirms the autochthonous quality of T. brasiliensis, T. pseudomaculata and R. nasutus populations in the "caatinga". The same autochthonous feature was evident in the P. megistus with relation to the Atlantic and inclusion forest environments. Nevertheless, it seems that this last triatominae bug becomes invasive in the "caatinga"; moreover similar patterns were evident for T. infestans and T. sordida in all the Northeast region studied. Results permit the conclusion that, in the regional epidemiological transmission of South American trypanosomiasis, P. megistus play an important role, followed, in this particular aspect, by T. brasiliensis. Depending on several factors, probably colonization density, T. pseudomaculata and T. sordida may come in second in this aspect. For the present, T. infestans low density in the region presents only potential risk. Routine control through the application of domiciliary chemicals will break transmission. However, at least in the peridomiciliary environment, reinfections by P. megistus will continue to occur in the forest regions, and T. brasiliensis, T. pseudomaculada and R. nasutus in the savanna "caatinga". Probably this will be due to natural foci that will supply the human environment. Therefore, epidemiological surveillance must to take these several aspects into account and to increase its efficiency by research development