Mechanisms of new-onset atrial fibrillation complicating acute coronary syndrome

Construction of a predictive model for new-onset atrial fibrillation after acute myocardial infarction based on P-wave amplitude in lead V1

BACKGROUND

In this study, we aimed to identify the risk factors for new-onset atrial fibrillation (NOAF) after postcoronary intervention in patients with acute myocardial infarction (AMI) and to establish a nomogram prediction model.

METHODS

The clinical data of 506 patients hospitalized for AMI from March 2020 to February 2023 were retrospectively collected, and the patients were randomized into a training cohort (70%; n = 354) and a validation cohort (30%; n = 152). Independent risk factors were determined using least absolute shrinkage and selection operator and multivariate logistic regression. Predictive nomogram modeling was performed using R software. Nomograms were evaluated based on discrimination, correction, and clinical efficacy using the C-statistic, calibration plot, and decision curve analysis, respectively.

RESULTS

The multivariate logistic regression analysis showed that P-wave amplitude in lead V1, age, and infarct type were independent risk factors for NOAF, and the area under the receiver operating characteristic curve of the training and validation sets was 0.760 (95% confidence interval [CI] 0.674-0.846) and 0.732 (95% CI 0.580-0.883), respectively. The calibration curves showed good agreement between the predicted and observed values in both the training and validation sets, supporting that the actual predictive power was close to the ideal predictive power.

CONCLUSIONS

P-wave amplitude in lead V1, age, and infarct type were independent risk factors for NOAF in patients with AMI after intervention. The nomogram model constructed in this study can be used to assess the risk of NOAF development and has some clinical application value.

Does Atrial Fibrillation Deteriorate the Prognosis in Patients With Septic or Cardiogenic Shock?

Atrial fibrillation (AF) is associated with increased risk of mortality in various clinical conditions. However, the prognostic role of preexisting and new-onset AF in critically ill patients, such as patients with septic or cardiogenic shock remains unclear. This study investigates the prognostic impact of preexisting and new-onset AF on 30-day all-cause mortality in patients with septic or cardiogenic shock. Consecutive patients with sepsis, or septic or cardiogenic shock were enrolled in 2 prospective, monocentric registries from 2019 to 2021. Statistical analyses included Kaplan-Meier, multivariable logistic, and Cox proportional regression analyses. In total, 644 patients were included (cardiogenic shock: n = 273; sepsis/septic shock: n = 361). The prevalence of AF was 41% (29% with preexisting AF, 12% with new-onset AF). Within the entire study cohort, neither preexisting AF (log-rank p = 0.542; hazard ratio [HR] 1.075, 95% confidence interval [CI] 0.848 to 1.363, p = 0.551) nor new-onset AF (log-rank p = 0.782, HR = 0.957, 95% CI 0.683 to 1.340, p = 0.797) were associated with 30-day all-cause mortality compared with non-AF. In patients with AF, ventricular rates >120 beats/min compared with ≤120 beats/min were shown to increase the risk of reaching the primary end point in AF patients with cardiogenic shock (log-rank p = 0.006, HR 1.886, 95% CI 1.164 to 3.057, p = 0.010). Furthermore, logistic regression analyses suggested increased age was the only predictor of new-onset AF (odds ratio 1.042, 95% CI 1.018 to 1.066, p = 0.001). In conclusion, neither the presence of preexisting AF nor the occurrence of new-onset AF was associated with the risk of 30-day all-cause mortality in consecutive patients admitted with cardiogenic shock.

TRIM21 deficiency protects against atrial inflammation and remodeling post myocardial infarction by attenuating oxidative stress

Atrial remodeling is a major contributor to the onset of atrial fibrillation (AF) after myocardial infarction (MI). Tripartite motif-containing protein 21 (TRIM21), an E3 ubiquitin protein ligase, is associated with pathological cardiac remodeling and dysfunction. However, the role of TRIM21 in postmyocardial infarction atrial remodeling and subsequent AF remains unclear. This study investigated the role of TRIM21 in post myocardial infarction atrial remodeling using TRIM21 knockout mice and explored the underlying mechanisms by overexpressing TRIM21 in HL-1 atrial myocytes using a lentiviral vector. The expression of TRIM21 in the left atrium of the mouse MI model was significantly elevated. TRIM21 deficiency alleviated MI-induced atrial oxidative damage, Cx43 downregulation, atrial fibrosis and enlargement, and abnormalities in electrocardiogram parameters (prolongation of the P-wave and PR interval). TRIM21 overexpression in atrial myocyte HL-1 cells further enhanced oxidative damage and Cx43 downregulation, whereas these effects were reversed by the reactive oxygen species scavenger N-acetylcysteine. The findings suggest that TRIM21 likely induces Nox2 expression mechanistically by activating the NF-κB pathway, which in turn leads to myocardial oxidative damage, inflammation, and atrial remodeling.

New Onset Atrial Fibrillation in STEMI Patients: Main Prognostic Factors and Clinical Outcome

The indications for the treatment of patients with known atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) are clear, while less is available about the management of new-onset AF (NOAF) during ST-segment elevation myocardial infarction (STEMI). The aim of this study is to evaluate mortality and clinical outcome of this high-risk subgroup of patients. We analyzed 1455 consecutive patients undergoing PCI for STEMI. NOAF was detected in 102 subjects, 62.7% males, with a mean age of 74.8 ± 10.6 years. The mean ejection fraction (EF) was 43.5 ± 12.1% and the mean atrial volume was increased (58 ± 20.9 mL). NOAF occurred mainly in the peri-acute phase and had a very variable duration (8.1 ± 12.5 min). During hospitalization, all the patients were treated with enoxaparin, but only 21.6% of them were discharged with long term oral anticoagulation. The majority of patients had a CHA2DS2-VASc score >2 and a HAS-BLED score of 2 or 3. The in-hospital mortality was 14.2%, while the 1-year mortality was 17.2% and long-term mortality 32.1% (median follow-up 1820 days). We identified age as an independent predictor of mortality both at short- and long-term follow-ups, while EF was the only independent predictor for in-hospital mortality and arrhythmia duration for 1-year mortality. At the 1-year follow-up, we recorded three ischemic strokes and no bleeding complications.

Nutritional Status as a Risk Factor for New-Onset Atrial Fibrillation in Acute Myocardial Infarction

Purpose

Our study aimed to identify new-onset atrial fibrillation (NOAF) risk factors in acute myocardial infarction (AMI) patients after treatment with percutaneous coronary intervention (PCI) and investigate whether their nutritional status can be a predicting factor of NOAF.

Patients and Methods

We analyzed 662 AMI patients after PCI for NOAF occurrence during follow-up hospitalization and divided them into an NOAF and non-NOAF group. The patients' nutritional status was assessed using the controlling nutritional status (CONUT) score and geriatric nutritional risk index (GNRI). The Kaplan‒Meier analysis was used to assess NOAF-free survival in varying degrees of malnutrition. Cox proportional hazards models were used to identify the risk factors for NOAF.

Results

Eighty-four (12.7%) patients developed NOAF during hospitalization. There was a statistically significant difference in the occurrence of NOAF among different categories of nutritional status. The CONUT score and GNRI classifications were independent predictors of NOAF. NOAF occurrence was associated with older age, higher uric acid levels, higher N-terminal pro-B-type natriuretic peptide levels, greater left atrial size, and worse Killip class upon admission.

Conclusion

The nutritional status can affect NOAF occurrence in AMI patients after PCI. The CONUT score and GNRI are ideal tools for evaluating the nutritional status of AMI patients, with an excellent predictive effect on NOAF.

Efficacy and safety of oral anticoagulants in elderly patients with stable coronary artery disease and atrial fibrillation

Background

This study aimed to evaluate the efficacy and safety of oral anticoagulants (OACs) in real-world elderly patients with comorbidities of stable coronary artery disease (SCAD) and atrial fibrillation (AF).

Methods

Elderly patients (aged ≥ 65 years old) diagnosed with SCAD and AF were consecutively recruited and grouped into patients with or without oral anticoagulant (OAC) treatment. Follow-up was performed for 5 years. Major adverse cardiac events (MACEs) were defined as a composite of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and systemic embolism. Major bleeding outcomes were defined as events that were type ≥ 3 based on the Bleeding Academic Research Consortium (BARC) criteria. The net clinical outcomes were defined as the combination of MACEs and bleeding of BARC type ≥ 3.

Results

A cohort of 832 eligible patients (78 ± 6.70 years) was included. Compared to the patients without OAC treatment (n = 531, 63.82%), the patients treated with OAC (n = 301, 36.18%) were much younger, had higher body mass index (BMI), and had lower prevalence of heart failure, chronic obstructive pulmonary disease (COPD), renal insufficiency, and previous myocardial infarction. During the follow-up of 5 years, compared to the patients without OAC treatment, patients with OAC had a significantly lower risk of MACEs (20.60% vs. 58.95%, adjusted HR: 0.21, 95% CI: 0.15–0.30, p < 0.001) but a higher risk of BARC ≥ 3 bleeding events (4.65% vs. 1.32%, adjusted HR: 4.71, 95% CI: 1.75–12.64, p = 0.002). In combination, a lower risk of net clinical outcomes could be observed in the patients with OACs (23.26% vs. 58.96%, adjusted HR: 0.27, 95% CI: 0.19–0.38, p < 0.001). Among the patients with OAC treatment, no significant difference was found for MACEs or BARC ≥ 3 bleeding events between the patients with or without comedications of oral antiplatelet agents.

Conclusions

A net clinical benefit of efficacy and safety could be observed in OAC-treated elderly patients with SCAD and AF. This benefit is independent of the comedications of oral antiplatelet treatment.

Colchicine: protection of the brain beyond the heart?

Not applicable for an editorial.

Assessment of the CHA2DS2-VASc Score for the Prediction of Death in Elderly Patients With Coronary Artery Disease and Atrial Fibrillation

Purpose: Coronary artery disease (CAD) and atrial fibrillation (AF) often coexist and lead to a much higher risk of mortality in the elderly population. The aim of this study was to investigate whether the CHA₂DS₂-VASc score could predict the risk of death in elderly patients with CAD and AF.

Methods: Hospitalized patients aged ≥65 years with a diagnosis of CAD and AF were recruited consecutively. Patients were divided into 5 groups according to the CHA₂DS₂-VASc score (≤2, =3, =4, =5, and ≥6). At least a 1-year follow-up was carried out for the assessment of all-cause death.

Results: A total of 1,579 eligible patients were recruited, with 582 all-cause deaths (6.86 per 100 patient-years) occurring during a follow-up of at least 1 year. With the increase in the CHA₂DS₂-VASc score, the 1-year and 5-year survival rate decreased (96.4% vs. 95.7% vs. 94.0% vs. 86.5% vs. 85.7%, respectively, P < 0.001; 78.4% vs. 68.9% vs. 64.6% vs. 55.5% vs. 50.0%, respectively, P < 0.001). Compared with the patients with CHA₂DS₂-VASc score <5, for patients with CHA₂DS₂-VASc score ≥5, the adjusted hazard ratio for death was 1.78 (95% CI: 1.45–2.18, P < 0.001). The predictive values of the CHA₂DS₂-VASc score ≥5 for in-hospital (C-index = 0.66, 95% CI: 0.62–0.69, P < 0.001), 1-year (C-index = 0.65, 95% CI: 0.63–0.67, P < 0.001) and 5-year (C-index = 0.60, 95% CI: 0.59–0.61, P < 0.001) death were in comparable.

Conclusion: In elderly patients with concomitant CAD and AF, the CHA₂DS₂-VASc score can be used to predict death with moderate accuracy.

Clinical Significance of Atrial Fibrillation Status in Patients With Percutaneous Coronary Intervention

Background

Patients undergoing percutaneous coronary intervention (PCI) often develop atrial fibrillation (AF). We investigated the clinical effects of AF status on in-hospital mortality and complications in patients with PCI using a recent large-scale nationwide dataset.

Methods

Using a claims-based dataset from 1022 hospitals in Japan for the time period between 2012 and 2016, patients with PCI were identified and classified into 3 groups according to AF status: no AF, prevalent AF before admission, and incident AF after admission. In-hospital mortality, complications, and medical costs were compared in crude and propensity-matched cohorts.

Results

In 659,525 hospitalized patients undergoing PCI, prevalent AF and incident AF were observed in 6.0% and 1.3% patients, respectively; the AF rates increased over 5 years. A greater proportion of older patients and patients with comorbidities had both of these categories of AF; undergoing PCI for acute coronary syndrome was common in incident AF. Both prevalent AF and incident AF were associated with worse crude outcomes and complications during hospitalization. In propensity-matched cohorts, incident AF was associated with a higher in-hospital mortality rate, longer length of stay, higher direct costs, and higher rate of complications, including stroke and acute kidney injury, compared with prevalent AF. These outcomes, except length of in-hospital stay, did not change for either AF status over 5 years.

Conclusions

Prevalent AF and incident AF in patients undergoing PCI were both associated with deteriorating crude outcomes and complications; in particular, incident AF was associated with worse adjusted outcomes and complications. Further efforts are needed to improve patient outcomes in an aging society in which the incidence of AF is increasing.

Post-discharge antithrombotic management and clinical outcomes of patients with new-onset or pre-existing atrial fibrillation and acute coronary syndromes undergoing coronary stenting: Follow-up data of the MATADOR-PCI study

BACKGROUND

. Patients with concomitant atrial fibrillation (AF) and acute coronary syndromes (ACS) do not seem to receive proper antithrombotic therapies and present high rates of adverse clinical events.

METHODS

. We analyzed the follow-up data of the prospective, nationwide MATADOR-PCI registry. We assessed the use of antithrombotic strategies and the incidence of major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) at 6 months, in patients with new-onset or pre-existing AF admitted for ACS and treated with percutaneous coronary intervention (PCI).

RESULTS

. Out of the 588 patients enrolled in the registry and discharged alive (287 with pre-existing and 301 with new-onset AF), data at 6 months were obtained for 579 (98.5%) patients. Compared to hospital discharge, the rate of triple antithrombotic therapy was significantly reduced (from 76.4% to 23.6% and from 53.8% to 23.6%; both p<0.0001) while dual antithrombotic therapy (DAT) increased (from 11.8% to 56.3% and from 5.8% to 30.9%; both p<0.0001) at follow-up, in patients with pre-existing and new-onset AF, respectively. Among patients with a class IA indication to receive oral anticoagulation therapy (OAT), it was prescribed in 91% and 88% of patients with pre-existing and 64% and 62% of new-onset AF, at discharge and follow-up, respectively. At 6 months from discharge the overall rate of MACE was 8.4% and 7.6% (p=0.75), while NACE occurred in 10.8% vs 10.0% (p=0.74) of patients with pre-existing or new-onset AF, respectively.

CONCLUSIONS

. At follow-up, DAT was the most used antithrombotic strategy for both patients with pre-existing and new-onset AF with concomitant ACS. These two groups of patients presented comparable rates of MACE and NACE at 6 months.

Predictive value of CHA2DS2-VASc score combined with hs-CRP for new-onset atrial fibrillation in elderly patients with acute myocardial infarction

Background

New-onset atrial fibrillation (NOAF) is common during acute myocardial infarction (AMI) and independently associated with worse prognosis. We aimed to validate the discrimination performance of CHA2DS2-VASc score combined with hs-CRP in the prediction of NOAF after AMI in elderly Chinese population.

Methods

311 consecutive elderly patients (age ≥ 65 years old) with AMI from 1 January 2018 to 1 January 2019 without atrial fibrillation history were enrolled in our study. Univariable and multivariable logistic regression analyses were used to identify risk factors of NOAF. The discrimination performance of different score models were evaluated using ROC curve analysis and AUCs were compared using the Z test.

Results

30 (9.65%) patients developed NOAF during hospitalization. The NOAF group were older and had higher hs-CRP, initial Killip class, BNP, LAD, CHADS2 score, CHA2DS2-VASc score, in-hospital mortality and lower LVEF and ACEI/ARB use (P < 0.05 vs group without NOAF for all measures). In multivariate regression analyses, age (OR = 1.127, 95% CI 1.063–1.196, P < 0.001) and hs-CRP (OR = 1.034, 95% CI 1.018–1.05, P < 0.001) were independent predictors of NOAF. In ROC curve analyses, both CHADS2 score (AUC = 0.624, 95% CI 0.516–0.733, P = 0.026) and CHA2DS2-VASc score (AUC = 0.687, 95% CI 0.584–0.79, P = 0.001) had acceptable but unsatisfactory discrimination performance in predicting NOAF after AMI. The combined model with CHA2DS2-VASc score and hs-CRP showed a significant better predictive value (AUC = 0.791, 95% CI 0.692–0.891, P < 0.001) compared to that of the CHA2DS2-VASc score alone (Z test, P = 0.008).

Conclusion

The combined model with CHA2DS2-VASc score and hs-CRP had high accuracy in predicting post-AMI NOAF.

The interplay between atrial fibrillation and acute myocardial infarction

Atrial fibrillation is the most frequently occurring supraventricular arrhythmia in patients presenting with acute myocardial infarction. It is associated with worse outcomes when it coexists with acute myocardial infarction and results in increased morbidity and mortality. Both conditions are closely related to each other and share similar pathophysiological pathways. The management of atrial fibrillation in patients with acute myocardial infarction is challenging since triple antithrombotic therapy is indicated, but this results in a markedly increased risk of bleeding events and mortality. This review addresses the interactions between both conditions including common risk factors, possible mechanisms through which acute myocardial infarction contributes to development of atrial fibrillation and vice versa, and the problem of using anticoagulation in the management of these patients.

New-onset paroxysmal atrial fibrillation in acute myocardial infarction: increased risk of stroke

OBJECTIVE

To investigate the long-term prognostic implications of transient new-onset atrial fibrillation (AF) in patients with acute myocardial infarction (AMI).

DESIGN

Retrospective observational study.

SETTING

Single tertiary centre.

PARTICIPANTS

This study included 2523 patients who presented with AMI from 3 June 2003 to 24 February 2015, after the exclusion of those with prior AF or in-hospital death.

OUTCOME MEASURES

Patients were divided into three groups according to the occurrence and type of new-onset AF: (1) sinus rhythm (SR) group; (2) paroxysmal AF (PaAF: AF converted to SR prior to discharge) group and (3) persistent AF (PeAF: AF persisted during the hospitalisation) group. Post-discharge all-cause mortality and stroke incidences were compared between the groups.

RESULTS

New-onset AF was observed in 271 patients (10.7%; PaAF: 230, PeAF: 41). The median follow-up period was 7.2 years (IQR: 5.2-9.4). The incidence of all-cause death and stroke was highest in the PeAF group, followed by the PaAF and SR groups (all-cause mortality: 48.8% vs 26.5% vs 14.7%, p<0.001; stroke 22.0% vs 8.3% vs 4.4%, p<0.001). In the multivariable analysis, PaAF and PeAF were associated with an increased risk of stroke (PaAF, HR: 1.972, 95% CI: 1.162-3.346; PeAF, HR: 5.160, CI: 2.242-11.873) compared with SR. The PaAF group showed a higher incidence of post-discharge AF than the SR group (29.1% vs 4.2%, p<0.001).

CONCLUSIONS

New-onset AF following AMI is associated with poor long-term outcomes. Even when AF episodes are brief and are converted to SR, new-onset AF remains associated with an increased risk of recurrent AF and stroke.

Acute Left Ventricular Unloading Reduces Atrial Stretch and Inhibits Atrial Arrhythmias

BACKGROUND

Left atrium (LA) physiology is influenced by changes in left ventricular (LV) performance and load.

OBJECTIVES

The purpose of this study was to define the effect of acute changes in LV loading conditions on LA physiology in subacute myocardial infarction (MI).

METHODS

MI was percutaneously induced in 19 Yorkshire pigs. One to 2 weeks after MI, 14 pigs underwent acute LV unloading using a percutaneous LV assist device, Impella. The remaining 5 pigs underwent acute LV loading by percutaneous induction of aortic regurgitation. A pressure-volume catheter was inserted into the LA using a percutaneous transseptal approach, and LA pressure-volume loops were continuously monitored. Atrial arrhythmia inducibility was examined by burst-pacing of the right atrium. Nicotinamide adenine dinucleotide phosphate oxidase (NOX) levels and ryanodine receptor phosphorylation were examined in LA tissues to study the potential effect of stretch-dependent oxidative stress.

RESULTS

MI resulted in reduced LV ejection fraction and increased LV end-diastolic pressure with concomitant increase in LA pressure and volumes. Acute LV unloading resulted in a reduction of LV end-diastolic pressure, which led to proportional decreases in mean LA pressure and maximum LA volume. LA pressure-volume loops exhibited a pump flow-dependent, left-downward shift. This was associated with reduced LA passive stiffness, suggesting the alleviation of the LA stretch that was present after MI. Prior to acute unloading of the LV, 71% of the pigs were arrhythmia-inducible; LV unloading reduced this to 29% (p = 0.02). Time to spontaneous termination of atrial arrhythmias was decreased from median 55 s (range 5 to 300 s) to 3 s (range 0 to 59 s). In contrast, acute LV loading with aortic regurgitation increased LA pressure without a significant effect on arrhythmogenicity. Molecular analysis of LA tissue revealed that NOX2 expression was increased after MI, whereas acute LV unloading reduced NOX2 levels and diminished ryanodine receptor phosphorylation.

CONCLUSIONS

Acute LV unloading relieves LA stretch and reduces atrial arrhythmogenicity in subacute MI.

Early Versus Late New-Onset Atrial Fibrillation in Acute Myocardial Infarction: Differences in Clinical Characteristics and Predictors

New-onset atrial fibrillation (NOAF) during acute myocardial infarction (AMI) has significant consequences but is often misdiagnosed. The aim of the study was to evaluate predictors of NOAF throughout different phases of AMI. Patients with AMI admitted to a tertiary medical center were analyzed. Exclusion criteria were preexisting AF, AMI onset ≥24 hours prior to admission, in-hospital death, significant valvular disease, and in-hospital coronary artery bypass graft. Study population were AMI without-NOAF, early-AF (AF terminated within 24 hours of admission), and late-AF (beyond the first 24 hours). Overall 5946 patients were included, age: 64.8 ±14.8 years; 30% women. The incidence of NOAF was 4.6%: 1.6% early-AF, and 3% late-AF. Patients with NOAF comprised greater rate of women, cardiovascular risk-factors burden, severe left ventricular-dysfunction, pulmonary hypertension, valvular disorders, and left atrial enlargement compared with patients without-NOAF. Non-ST-elevation myocardial infarction and inferior-ST-elevation myocardial infarction (STEMI) were significantly more prevalent among early-AF group, while anterior-STEMI, in late-AF. The final multivariate models showed c-statistics of 0.73 and 0.76 for the prediction of new-onset early-AF and late-AF, respectively. In conclusion, there are different clinical predictors of early- versus late-NOAF. The study points out “high risk” AMI population for more meticulous heart rate monitoring for NOAF.

Value of Syntax Score II in Prediction of New-Onset Atrial Fibrillation in Patients With NSTE-ACS Undergoing Percutaneous Coronary Intervention

New-onset atrial fibrillation (NOAF) has been associated with poor outcome in patients with acute coronary syndromes (ACSs). The objective of this study was to investigate the relationship between the development of NOAF and severity of coronary artery disease using the SYNTAX score (SS) and SYNTAX score II (SSII) in patients with non-ST-segment elevation ACS (NSTE-ACS) who were treated with percutaneous coronary intervention (PCI). A total of 662 patients with NSTE-ACS were consecutively enrolled. The incidence of NOAF was 11.4% among the patients with NSTE-ACS. Mean age was significantly higher in NOAF group ( P = .011). White blood cell count, peak troponin I, high sensitivity C-reactive protein, uric acid, left atrial volume index, and ratio between early mitral inflow velocity and mitral annular early diastolic velocity were significantly higher in NOAF group (respectively, P = .024, P = .017, P = .002, P = .009, P = .025, P < .001, and P < .001). The hemoglobin, ejection fraction, and post PCI thrombolysis in myocardial infarction grade <3 were significantly lower in NOAF group ( P = 001, P = .010, P = .038). The SS and SSII were significantly higher in NOAF group (all P < .001). According to the results of multivariate logistic regression analysis, the SSII was correlated with NOAF ( P < .001) in the study groups. We demonstrated that high SSII is significantly associated with NOAF.

Contrast-induced nephropathy is associated with new-onset atrial fibrillation in acute coronary syndrome after cardiac catheterization: Systemic review and meta-analysis

INTRODUCTION

Contrast-induced nephropathy (CIN) is associated with increased cardiovascular morbidity and mortality in patients with acute coronary syndrome (ACS). Recent studies suggest that CIN is associated with new-onset atrial fibrillation (AF) in patients with acute coronary syndrome (ACS) who underwent catheterization. However, a systematic review and meta-analysis of the literature have not been done. We assessed the association between CIN in patients with ACS and new-onset AF by a systematic review of the literature and a meta-analysis.

HYPOTHESIS

CIN is associated with new-onset AF in patients with ACS.

METHODS

We comprehensively searched the databases of MEDLINE and EMBASE from inception to April 2018. Included studies were published cohort studies that compared new-onset AF after cardiac catheterization in ACS patient with CIN versus without CIN. Data from each study were combined using the random effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals.

RESULTS

Five studies from December 2009 to February 2018 were included in this meta-analysis involving 5,640 subjects with ACS (1,102 with CIN and 4,538 without CIN). Contrast-induced nephropathy significantly correlates with new-onset AF after cardiac catheterization (pooled risk ratio = 2.84, 95% confidence interval: 1.66-4.87, p < 0.001, I²  = 58%) CONCLUSIONS: Contrast-induced nephropathy is associated with new-onset AF threefold among patients with ACS after cardiac catheterization. Our study warranted further study to establish the causality between CIN and new-onset AF.

Predictors of new-onset atrial fibrillation in elderly patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

The development of atrial fibrillation (AF) during the course of acute coronary syndrome (ACS) is related to poor prognosis. Possible predictors of new-onset AF (NOAF) have not been adequately investigated in elderly patients with ACS undergoing percutaneous coronary intervention (PCI). We aimed to identify the factors associated with NOAF in such patients.

METHODS

A total of 308 elderly patients with ACS undergoing PCI were enrolled in the study. Patients were divided into two groups: without NOAF [254 patients, 64.6% men, age: 73.5 (69.0-79.0) years] and with NOAF [54 patients, 70.4% men, age: 75.0 (68.7-81.2) years]. Clinical, angiographic, and laboratory features including neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-high-density lipoprotein ratio (MHR) were compared between the groups.

RESULTS

The percentages of prior myocardial infarction (MI) (20.4 vs. 5.9%) and Killip III/ IV (24.1 vs. 7.1%), NLR [4.5 (2.6-7.2) vs. 3.2 (2.0-6.0)], and MHR [19.4 (15.7-26.5) vs. 12.9 (9.9-18.5)] were higher in patients with NOAF compared to the others (p = 0.020, < 0.001, 0.030, and < 0.001, respectively). In multivariate regression analysis, prior MI (OR 4.509, 95% CI 1.679-12.106, p = 0.003) and MHR (OR 1.102, 95% CI 1.054-1.152, p < 0.001) independently predicted NOAF. In addition, Killip III/IV was found to be an independent predictor of 6-month overall mortality (HR 2.949, 95% CI 1.218-7.136, p = 0.016).

CONCLUSIONS

Prior MI and MHR are independent predictors of NOAF in elderly patients with ACS undergoing PCI. Killip III/IV predicts 6-month overall mortality in such patients.

New-onset or Pre-existing Atrial Fibrillation in Acute Coronary Syndromes: Two Distinct Phenomena With a Similar Prognosis

INTRODUCTION AND OBJECTIVES

The management and risk stratification of patients with atrial fibrillation (AF) and acute coronary syndromes constitute a challenge. We aimed to evaluate the prognostic impact of AF whether present at admission or occurring during hospitalization for acute coronary syndromes, as well as trends in treatments and outcome.

METHODS

Data derived from 35 958 patients enrolled between 2004 and 2015 in the AMIS Plus registry were retrospectively analyzed.

RESULTS

Pre-existing AF (pre-AF) was present in 1644 (4.7%) while new-onset AF (new-AF) was evident in 309 (0.8%). Presentation with ST-segment elevation myocardial infarction and need for hemodynamic support was frequent in patients with AF, especially in those with new onset of the arrhythmia. A change of the medical and interventional approaches was observed with a progressive increase in oral anticoagulation prescription and referral for angiography and percutaneous coronary interventions in pre-AF patients. Despite different baseline risk profile and clinical presentations, both AF groups showed high in-hospital and 1-year mortality (in-hospital new-AF vs pre-AF [OR, 0.79; 95%CI, 0.53-1.17; P = .246]; 1-year mortality new-AF vs pre-AF [OR, 0.72; 95%CI, 0.31-1.67; P = .448]) Pre-AF but not new-AF independently predicted in-hospital mortality. While mortality declined over the study period for patients with pre-AF, it remained stable among new-AF patients.

CONCLUSIONS

While pre-AF is independently associated with in-hospital mortality, new-AF may reflect a worse hemodynamic impact of the acute coronary syndromes, with the latter ultimately driving the prognosis.