P3759Comparison of equations for renal function assessment and major adverse outcomes in atrial fibrillation: an analysis from the EORP-AF long-term general registry

Background

Several equations exist to estimate creatinine clearance according to serum creatinine values and baseline characteristics. The CKD-EPI equation is usually recommended in general population, while the Cockroft-Gault (CG) equation has been used in atrial fibrillation (AF) clinical trials.

Purpose

To perform a comparison between 6 different equations for evaluation of renal function in AF patients.

Methods

We calculated CKD-EPI, CG, body surface area adjusted CG (CG BSA), MDRD, BIS1 and FAS equations in AF patients enrolled in the EORP-AF Long-Term General Registry. Outcomes at 1-year follow-up were considered.

Results

Renal equations were calculated in 7725 patients. According to CKD-EPI mean (SD) creatinine clearance was 69.14 (21.06) mL/min/1.73 m2. Taking CKD-EPI as reference, the MDRD equation showed the highest agreement (weighted kappa [95% CI]: 0.843 [0.833–0.852]), while CK showed the lowest agreement (weighted kappa [95% CI]: 0.593 [0.580–0.606]. The remaining equations showed moderate agreement. Cox regression analysis showed that all equations were inversely associated with all major adverse outcomes [Figure]. The CKD-EPI equation showed modest predictive ability for the three outcomes (c-statistics: any TE/ACS/CV Death: 0.63379; CV Death: 0.68512; All-Cause Death: 0.67183), with all other equations reporting higher c-statistics (delta-c statistic ranging from +0.01497 for FAS equation for any TE/ACS/CV Death to +0.04547 for CG BSA for all-cause death) for all outcomes (all p<0.0001, for any equation for any outcome). Compared to CKD-EPI, all the other equations showed an improvement in prediction of outcomes, according to IDI and NRI, with the exception of FAS equation for any TE/ACS/CV Death. CG BSA equation showed the greatest improvement in prediction of outcomes compared to CKD-EPI (relative IDI: 21.9% for any TE/ACS/CV Death, 28.8% for CV Death, 34.4% for All-Cause Death).

Cox Regression Analysis

Conclusions

Compared to CKD-EPI equation, all the other equations for creatine clearance has stronger associations with adverse outcomes, with the CG BSA reporting the higher yield for all the outcomes considered.

P4800Estimated effect of NOACs compared to Vitamin K Antagonists in real-world atrial fibrillation patients: Data from FANTASIA Registry

Background

Despite of the effectiveness and safety profile of Non-vitamin K Antagonists Oral Anticoagulants (NOACs) even in real-world (RW) Atrial Fibrillation (AF) patients, Vitamin K Antagonists (VKAs) have remained widely used in clinical practice worldwide but the comparison with acenocoumarol therapy in RW is unknown.

Purpose

To estimate the potential absolute benefit in clinical adverse events if the AF patients anticoagulated with VKA therapy had been treated with NOACs.

Methods

We analyzed anticoagulated AF patients who were prospectively recruited into the multicentre FANTASIIA registry. Patients were treated with VKAs for at least 6 months prior to inclusion. The estimation of clinical adverse events avoided was calculated applying absolute risk reductions, relative risk reductions and hazard ratios from the meta-analysis of RW use of NOACs relative to VKAs.

Results

We analyzed 1,470 patients under VKA therapy (mean age 74.1±9.5 years; 56.4% male). Stroke rate with acenocoumarol treatment was 0.88%/year. The estimated rates for stroke using NOACs would be 0.80%/year for Dabigatran 150 mg; 0.76%/year for Rivaroxaban and 0.74%/year for Apixaban instead of VKA. No significant differences were observed between the different NOACs and VKA in stroke rate. Major bleeding with acenocoumarol was 3.40%/year. The estimated rates for major bleeding using NOACs would be 2.75%/year for Dabigatran 150 mg; 3.37%/year for Rivaroxaban and 2.18%/year for Apixaban instead of VKA. Apixaban was the only NOAC that showed a significant estimated reduction rates (p=0.046). Finally, the all-cause mortality rate with acenocoumarol was 4.69%/year. The estimated rates of all-cause mortality using NOACs would be 3.28%/year for Dabigatran 150mg; 4.88%/year for Rivaroxaban and 2.67%/year for Apixaban. Dabigatran and Apixaban showed significant estimated reduction rates with the highest reduction with Apixaban (Table).

Annual Rate reduction of adverse events

Conclusion

The absolute estimated effect of NOACs in the AF patients anticoagulated with VKA showed a significant reduction in adverse clinical events. Apixaban performed the highest estimated reduction in major bleeding and all-cause mortality in comparison with acenocoumarol.

P3612Validation of Charlson Comorbidity Index to predict adverse events in elderly patients with Atrial Fibrillation and Acute Coronary Syndrome: an analysis from LONGEVO-SCA Registry

Background

Aging is frequently characterized by the coexistence of several comorbid conditions that increase the adverse prognosis during hospitalization. There are few scores to analyze the impact of comorbidities in prognosis. Charlson Comorbidity Index (CCI). This score evaluates the burden of comorbidity in general population but the influence within cardiac diseases is unknown.

Purpose

The aim of this study was to analyze the relationship of CCI in adverse outcomes at short-term follow-up in elderly patients with atrial fibrillation (AF) admitted after an acute coronary syndrome (ACS).

Methods

The prospective multicenter LONGEVO-SCA included unselected elderly patients hospitalized after non-STACS. In this substudy, we analyze the influence of comorbidities in elderly AF patients, comparing high quartiles of CCI (Q3-Q4: high burden of comorbidities) to low quartiles (Q1-Q2) and the predictive performance of adverse events at 6 months follow-up of CCI.

Results

We analyzed 531 patients (mean age 84.4±3.6 years; 322 (60.6%) male). 128 (24.1%) had AF diagnosis. 91 (71.1%) patients were classified into Q1-Q2 and 37 (28.9%) patients into Q3-Q4. We analyzed the association of clinical factors and adverse events and, after Cox multivariate regression analysis, CCI was independently associated with readmissions [HR 1.19, 95% CI (1.02–1.39); p=0.020) and all-cause mortality [HR 1.32, 95% CI (1.09–1.59); p=0.003]. Patients into Q3-Q4 had higher risk of mortality than patients into Q1-Q2 [HR 5.52, 95% CI (1.01–30.3); p=0.049]. Kaplan Meier analysis showed that AF patients into Q3-Q4 had significantly worse prognosis during the follow-up with high risk of all-cause mortality (p=0.034) and readmissions due to ACS (p=0.027). We observed good predictive performance of CCI for mortality (c-statistic 0.705; p<0.001) and modest predictive performance for readmissions (c-statistic 0.627; p<0.001).

Event Free Survival according Charlson

Conclusions

Patients into high quartiles of CCI had higher risk of adverse events during the follow-up. CCI was an independent predictor of all-cause mortality and readmissions in elderly patients. Indeed, this is the first time to validate CCI to predict adverse events in AF patients with ACS.

P2530Frailty assessment in atrial fibrillation patients with acute coronary syndromes: a subanalysis from LONGEVO-SCA registry

Background

Different studies have observed a significant correlation between frailty, morbidity and mortality in elderly patients with cardiovascular diseases.Several scores have been developed to assess frailty in elderly patients. The FRAIL scale is a bed-side and easy tool that evaluates 5 items: fatigue, resistance, ambulation, concomitant diseases and weight loss. However, the evaluation of frailty status in AF patients with ACS is scarce.

Purpose

The aim of this study was to analyze the management of elderly patients with AF and ACS and the predictive value of frailty for adverse events.

Methods

The prospective multicentre LONGEVO-SCA enrolled unselected elderly patients hospitalized after non-STACS. In this substudy, we divided patients according to rhythm status (AF or sinus rhythm [SR]) and to frail status. We validated the predictive performance of FRAIL scores for adverse events at 6 months follow-up.

Results

We analyzed 531 patients (mean age 84.4±3.6 years; 322 (60.6%) male). 128 (24.1%) had AF diagnosis and 145 (27.3%) patients were frail. Frail AF patients had higher risk of global mortality [HR 2.61, (95% CI 1.28–5.31; p=0.008)], readmissions [HR 2.28, (95% CI 1.37–3.80); p=0.002)] and the composite endpoint [HR 2.28, (95% CI 1.44–3.60); p<0.001)] compared with non-frail SR patients. After multivariate adjustment, Frail score [HR 1.41; 95% CI (1.02–1.97); p=0.040] was independently associated with mortality. Kaplan Meier analysis showed that frail AF patients had significantly worse prognosis during the follow-up with high risk of global mortality (log rank p=0.024) and readmission (log rank p<0.001) followed closely by those frail SR patients.

Event Free Survival according Frailty

Conclusions

In the LONGEVO-SCA registry, frail AF patients have 2-fold risk of adverse events compared to non-frail SR patients. Frailty status was an independent condition associated with high risk of adverse events at 6 months of follow-up.

P3840Impact of potent P2Y12 inhibitors in adverse events reduction in diabetic patients with Acute Coronary Syndromes. An analysis from ACHILLES Registry

Background

Diabetic patients (DM) with an acute coronary syndrome (ACS) have a worse prognosis than non-diabetic patients. The new P2Y12 inhibitors, both ticagrelor and prasugrel, have shown efficacy in cardiovascular event reduction in patients with DM and ACS.

Purpose

The main objective of this study was to analyze the use of antiplatelet agents, prognosis and adverse events during the follow-up in diabetic patients admitted after an acute coronary syndrome.

Methods

These patients belong to ACHILLES registry. All patients with type 1 ACS were included prospectively in a national, prospective and multicenter registry. We analyzed baseline characteristics and comorbidities focusing on the presence of DM and the use of potent antiplatelet agents (ticagrelor and prasugrel) in those patients. After 1 year of follow-up, adverse events in diabetic patients were analyzed according to the type of antiplatelet used [clopidogrel vs new antiplatelet drugs (NAD)].

Results

Of 1,717 patients, 1,294 patients [mean age 65.0±13.3 years, 952 (73.6%) male] were finally analyzed (excluding patients discharged with oral anticoagulation). Diabetic patients had high prevalence of cardiovascular risk factors such as hypertension (54.9% vs 81.1%; p<0.001), dyslipidemia (50.7% vs 72.8%; p<0.001) or chronic kidney disease (22.1% vs 31.9%; p<0.001). Diabetic patients had also higher rate of non-invasive management of ACS compared to non-diabetic patients (4.5% vs 9.1%; p=0.002). At discharge, the use of NAD in patients with DM was 40.4% compared to 50.8% in non-diabetic patients (p<0.001).

After 1 year of follow-up, 64 (5.0%/year) patients had a new ACS, 46 (3.6%/year) patients died due to cardiovascular causes, 76 (6.1%/year) died for any cause and 28 (2.2%/year) patients had a major bleeding events. The use of clopidogrel in diabetic patients was associated with an increase in all-cause mortality [HR 2.90; 95% CI (1.27–6.629), p=0.011] and in MACE [HR 2.14; 95% CI (1.22–3.77), p=0.008.] Diabetic patients treated with NAD had no differences in terms of major bleeding but those patients presented a significant reduction in cardiovascular mortality and MACE with NAD use.

Event Free Survival according NAD Use

Conclusions

Patients with DM and ACS had high prevalence of concomitant cardiovascular risk factors but lower use of NAD compared with non-diabetic patients, despite DM patients had greater baseline risk. The use of NAD therapy was associated with a significant reduction in all-cause mortality, cardiovascular mortality and MACE without differences in major bleeding events.

P1752Impact of frailty addition in ischemic and bleeding risk scores in elderly patients with Atrial Fibrillation and Acute Coronary Syndrome: a subanalysis from LONGEVO-SCA registry

Background

The prevalence of Atrial Fibrillation (AF) and Acute Coronary Syndrome (ACS) increases with age. Frail older adults are at high risk of multiple adverse events during admission and short term mortality. FRAIL score is an easy tool that evaluates: fatigue, resistance, ambulation, concomitant diseases and weight loss.

Purpose

The aim of this study was to validate FRAIL score in AF elderly patients with ACS related to adverse events and the impact of its addition in clinical scores.

Methods

The prospective multicenter LONGEVO-SCA enrolled unselected elderly patients hospitalized after non-STACS. We analyzed the predictive performance of FRAIL score in AF subgroup for adverse events (primary endpoint mortality or readmission) and the impact of frailty addition in ischaemic and bleeding scores.

Results

We analyzed 531 patients. 128 (24.1%) of them have AF (main age 84.6±3.7 years; 78 (61%) male) and 27.3% were frail (defined by FRAIL score ≥3). Frail AF patients had more prevalent comorbidities and received less evidence-based ACS therapies at discharge as oral anticoagulation (66% vs 60%; p<0.001) or statins 96.3% vs 82.6%; p<0.001). We analyzed the predictive performance of FRAIL score to adverse events and observed a modest predictive performance for mortality (c-statistic 0.648; 95% CI [0.605–0.690]; p<0.001), readmissions (c-statistic 0.600; 95% CI [0.557–0.642]; p<0.001) and for composite endpoint (c-statistic 0.620; 95% CI [0.577–0.663]; p<0.001). We compared the addition of FRAIL score to the original risk scores and observed a significant improvement for the primary endpoint with the addition to CHA2DS2-Vasc score (p=0.009), GRACE (p<0.001) and CRUSADE scores (p<0.001). (Table)

C-indexes for mortality or readmissions C-index 95% CI p p* Z* CHA2DS2-VASc score 0.619 0.576 to 0.662 <0.001 0.009 2.586 CHA2DS2-VASc score + FRAIL 0.641 0.598 to 0.683 <0.001 HAS-BLED score 0.649 0.606 to 0.691 <0.001 0.445 0.764 HAS-BLED score + FRAIL 0.634 0.590 to 0.675 <0.001 GRACE score 0.599 0.554 to 0.644 0.006 0.001 3.930 GRACE score + FRAIL 0.602 0.556 to 0.646 <0.001 CRUSADE score 0.660 0.613 to 0.705 0.051 0.001 3.287 CRUSADE score + FRAIL 0.664 0.617 to 0.709 <0.001 CI: Confidence interval. *For c-index comparison. p: P value.

Conclusions

This is the first validation of the FRAIL score in AF patients under ACS with a modest predictive performance to adverse events. The addition of frailty to clinical scores improved the predictive performance to adverse events in AF patients.

P1563CHA2DS2-VASc score predicts mortality and readmission in octogenarian patients with non-ST-segment elevation myocardial infarction

Background

CHA2DS2-VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We ought to study if this score predicts outcomes in elderly patients with Non ST-segment Elevation Myocardial Infarction (NSTEMI).

Methods

The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEMI aged ≥80 years. Data to calculate CHA2DS2-VASc Score were available in 523 patients (98.3%). They were classified according to CHA2DS2-VASc Score: group 1 (score 0–4), and 2 (5–9). We studied outcomes in terms of mortality or readmission at 6 months follow-up.

Results

A total of 266 patients (51%) had a high CHA2DS2-VASc Score (group 2). They were more often women, with more cardiovascular risk factors like hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, p=0.001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment and frailty) and Charlson index were worse in this group (all, p=0.001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, p=0.001), and developed new onset AF more often during admission (12.4% vs. 6.6%, p=0,024). At six months follow-up, patients in group 2 had higher reinfarction, all cause mortality, and mortality or readmission rates (all, p=0.001). (Table) A CHA2DS2-VASc Score >4 predicted mortality (HR 2,60 [95% CI 1,48–4,55], p<0,001) (Figure 1) and was associated with mortality or readmission at 6 months (HR 2.07 [CI 95% 1.51–2.84], p<0.001).

CHADS VASC2 0–4 (n=257) CHADS >4 (n=266) p Geriatric syndromes   Barthel Index 94 (13) 85 (22) 0.001   Lawton brody 6.2 (2) 4.9 (3) 0.001   Charlson Index 1.5 (1) 3.3 (2) 0.001 Cognitive impairment 0.001   No 201 (79.1) 155 (58.7)   Mild 49 (19.3) 100 (37.9)   Severe 4 (1.6) 9 (3.4) Nutritional risk (MNA-SF*) 122 (48) 149 (57.1) 0.040 Frailty (FRAIL scale) 0.001   Non-frail 111 (43.2) 69 (25.9)   Prefrail 102 (39.7) 101 (38)   Frail 44 (17.1) 96 (36.1) Outcomes at 6 months   Reinfarction 26 (6.9) 16 (13.9) 0.018   Mortality or readmission 111 (28.9) 60 (50.4) 0.001   All cause mortality 38 (9.9) 24 (20.2) 0.003

Conclusions

A CHA2DS2-VASc sore>4 is present in half of octogenarians with NSTEMI and is associated with a poor outcome.

P939Cardiovascular outcomes in patients with Acute Coronary Syndrome and previous cardiovascular disease. An analysis from ACHILLES Registry

Background

Patients with acute coronary syndrome (ACS) and previous cardiovascular disease (CVD) [stroke, peripheral arterial disease (PAD) or coronary artery disease (CAD)] are at high risk of serious events and mortality. Current clinical guidelines recommend new antiplatelet drugs (NAD) for high cardiovascular risk patients with ACS; however, these drugs are underused in different scenarios.

Purpose

The aim of this study was to analyze the use of NAD and advese events in patients with ACS an previous CVD.

Methods

ACHILLES registry is and observational, multicenter and prospective registry of ACS patients. 1717 ACS patients were consecutively included in this study from 3 tertiary Hospitals. Of them, 641 (37.33%) suffered from previous CVD: 149 patients with stroke, 154 patients with PAD and 541 patients with CAD. Bleeding, mortality and major adverse cardiac events (MACE) at 1 year of follow-up after hospital discharge were analyzed.

Results

NADs administration during hospital stay and at discharge was less frequent in patients with previous CVDs. Cox analysis in this cohort of patients showed that clopidogrel prescription at discharge was independently associated with MACEs [HR: 1.59 (95% CI 1.03–2.45); p=0.036] and with death [HR: 1.99 (95% CI 1.00–3.98); p=0.049] in multivariate analysis. More specifically, when ticagrelor prescription at discharge was compared with clopidogrel prescription, a significant death reduction was found in both, the univariate and the multivariate Cox analysis [HR: 4.54 (95% CI 2.26–9.13); p<0.001 and HR: 2.61 (95% CI 1.16–5.90); p=0.021, respectively].

KM curves according NAD and CVD disease

Conclusion

New antiplatelet drugs, especially ticagrelor, showed lower rates of mortality in patients with CVD without differences for bleeding. Despite the recommendations of current clinical guidelines for high risk patients with ACS, the use of NADs is very low in “real-life” patients with previous CVD.