Atrial fibrillation (AF) is the most common persistent arrhythmia in the general population, with a prevalence of about 1-2%. It is believed that about 5-6 million people in Europe suffer from AF, and that number is increasing due to the aging of the population and lifespan extension. Although we do not currently have accurate epidemiological data or a registry in Croatia, assuming that the prevalence is the same as in Europe, we can estimate 40-50000 people suffer from AF in Croatia (
Atrial fibrillation is associated with increased total mortality and morbidity and risk of stroke and heart failure. In addition to morbidity and mortality effects, AF represents a large socioeconomic issue due to the financial burden of treatment, rehabilitation, sick leave, and early retirement. For example, in Germany in 2006 the treatment costs alone for patients with AF at the national level amounted to almost 700 million euros. Due to the above, early diagnosis and adequate treatment are extremely important in patients with AF (
AF treatment focuses primarily on reducing the risk of stroke and mortality as well as symptom reduction in the patient. Currently, only anticoagulation therapy has been proven to reduce total mortality through stroke risk reduction. Symptom reduction in the form of frequency or rhythm control has not yet been unambiguously shown to affect mortality (
Pulmonary vein isolation for atrial fibrillation was developed as a way to maintain sinus rhythm without using antiarrhythmic drugs, and studies have consistently shown it to be superior in comparison with antiarrhythmic drugs for certain patient groups. Point-by-point radiofrequency ablation using X-ray imaging was developed initially, but it has been improved over the years with the development of 3D mapping systems and new irrigation catheters (
As stated above, an estimated 40-50000 people suffer from AF in Croatia. This is a serious public health and economic problem. Because there are no accurate data, in 2016 the Working Group on Arrhytmias and Cardiac Pacing of the Croatian Cardiac Society started the Atrial Fibrillation Registry that will initially cover part of the population (hospitals) and is planned grow into a national AF registry in the future that would provide correct data on patient numbers, treatment, and socioeconomic impacts.
In the domain of medication therapy, primarily anticoagulation therapy, novel oral anticoagulant drugs have recently appeared on the market in Croatia and have demonstrated themselves comparable to or better than the gold standard warfarin therapy. Although use of these drugs is widespread in the European Union, since they are either not covered by insurance or incur additional fees these drugs are currently only available to a small number of patients in Croatia. Croatia also belongs to the group of countries with a large number of patients using warfarin that do not have adequately regulated international normalized ratios (INR). The question remains whether there is a need for standardization in educating/monitoring patients using anticoagulation therapy, i.e. opening clinics/polyclinics for AF and anticoagulation therapy.
As to interventional treatment (pulmonary vein isolation), there has been great progress in Croatia over the past few years. The first pulmonary vein isolation procedures were performed in 2009. Today, pulmonary vein isolation is performed in five centers, of which three perform over 100 such ablations annually. Almost all globally available technologies are in use, with RF ablation being the most common method and amounting to 85% of all pulmonary vein isolation procedures performed in 2015. Last year, a total of 446 pulmonary vein isolation procedures was performed (
The number of ablations for atrial fibrillation in Croatia.
The situation regarding ablation for atrial fibrillation in Europe (the total ablation rate per million inhabitants).
Just like in the rest of the world, there has been great progress in the treatment of patients with AF in Croatia. The success rate of ablation therapy for paroxysmal atrial fibrillation and short-term persistent atrial fibrillation (<1 year in duration) is already rising to as much as 90% at one-year follow-up in high-volume centers. Ablation therapy for long-term persistent atrial fibrillation has not been nearly as successful, despite the employment of different strategies of ablation therapy. Additionally, accurate verification of results requires further efforts and investments into national registries, as well as standardization in treatment and follow-up for these patients.
In conclusion, ablation therapy has, over a short period of time, become the standard treatment in the Republic of Croatia, and the number of procedures being performed is now at the level of Central European countries.