Relation of Atrial Fibrillation in Acute Myocardial Infarction to In-Hospital Complications and Early Hospital Readmission

Atrial Fibrillation Complicating Acute Myocardial Infarction: Prevalence, Impact, and Management Considerations

PURPOSE OF REVIEW

Atrial fibrillation (AF) and myocardial infarction (MI) often coexist, and this overlapping nature leads to heightened morbidity and increases the need for comprehensive risk management strategies. The precise trajectory and implications of atrial fibrillation complicating myocardial infarction remain subjects of debate, with divergent reports presenting varying accounts. This review seeks to provide an in-depth exploration of the existing literature to cover the predictors, implication, and available management of new onset atrial fibrillation (NOAF) complicating acute myocardial infarction (AMI).

RECENT FINDINGS

Clinical risk factors, laboratory markers, echocardiographic findings, and angiographic data can be used to assess patients at risk of developing NOAF post-AMI. The diagnosis of NOAF post MI has been associated with overall worse short- and long-term prognosis with increased risk for mortality, cardiogenic shock, stroke, and bleeding, along with reduced rates of coronary angiography and percutaneous coronary intervention, and higher risk of future recurrence of AF and ischemic stroke. Despite the paucity of preventative treatment, the optimal management of acute coronary syndrome and the use of guideline directed therapy do decrease the risk of development of atrial fibrillation post myocardial infarction.

Acute Ischemic Stroke and Transient Ischemic Attack in ST-Segment Elevation Myocardial Infarction Patients Who Underwent Primary Percutaneous Coronary Intervention

BACKGROUND

Acute ischemic stroke (AIS) is a rare but critical complication following ST-elevation myocardial infarction (STEMI). The risk of AIS or transient ischemic attack (TIA) may be amplified by invasive procedures, including primary percutaneous coronary intervention (PCI). This study aimed to investigate the factors associated with in-hospital AIS/TIA in patients with STEMI who required primary PCI.

METHODS

We included 941 STEMI patients who underwent primary PCI and divided them into an AIS/TIA group (n = 39) and a non-AIS/TIA group (n = 902), according to new-onset AIS/TIA. The primary interest was to find the factors associated with AIS/TIA by multivariate logistic regression analysis. We also compared clinical outcomes between the AIS/TIA and non-AIS/TIA groups.

RESULTS

The incidence of in-hospital deaths was significantly higher in the AIS/TIA group (46.2%) than in the non-AIS/TIA group (6.3%) (p < 0.001). Multivariate analysis revealed that cardiogenic shock (OR 3.228, 95% CI 1.492-6.986, p = 0.003), new-onset atrial fibrillation (AF) (OR 2.280, 95% CI 1.033-5.031, p = 0.041), trans-femoral approach (OR 2.336, 95% CI 1.093-4.992, p = 0.029), use of ≥4 catheters (OR 3.715, 95% CI 1.831-7.537, p < 0.001), and bleeding academic research consortium (BARC) type 3 or 5 bleeding (OR 2.932, 95% CI 1.256-6.846, p = 0.013) were significantly associated with AIS/TIA.

CONCLUSION

In STEMI patients with primary PCI, new-onset AIS/TIA was significantly associated with cardiogenic shock, new-onset AF, trans-femoral approach, the use of ≥4 catheters, and BARC type 3 or 5 bleeding. We should recognize these modifiable and unmodifiable risk factors for AIS/TIA in the treatment of STEMI.

Chest pain workup in the presence of atrial fibrillation: impacts on troponin testing, myocardial infarction diagnoses, and long-term prognosis

AIMS

Patients presenting to the emergency department (ED) with chest pain require evaluation for acute coronary syndrome (ACS). Atrial fibrillation (AF) can lead to troponin (cTn) elevation in the absence of ACS. There is limited evidence informing the impact of AF on the diagnostic performance of cTn testing for the diagnosis of Type 1 myocardial infarction (T1MI), or the association between AF and long-term outcomes in this context.

METHODS AND RESULTS

This study used the IMPACT and ADAPT study databases to compile a combined cohort of 3496 adults presenting to ED with chest pain between 2007 and 2014, with early cTn testing during ED workup. The mean age was 56.6 years, and 40.2% were female. Outcomes included adjudicated diagnoses for the index admission and mortality to 1-year after presentation. The specificity of initial cTn testing for T1MI diagnosis was lower for patients in AF compared with those not in AF (79.2% vs. 95.4%, P < 0.001), largely due to a relative increase in Type 2 myocardial infarction diagnoses. Sensitivity for T1MI did not differ between patients with or without AF (88.5% vs. 91.5%, P = 0.485). AF was associated with increased 1-year mortality (10.4% vs. 2.3%, P < 0.001), although this was not significant on multivariable analysis.

CONCLUSION

The specificity of serial cTn testing for the diagnosis of T1MI in patients presenting to ED with chest pain is reduced in the presence of AF. Further studies are needed to establish whether optimised cTn thresholds for patients with AF can improve workup and outcomes.

Incidence, clinical predictors, and clinical effect of new-onset atrial fibrillation in myocardial infarction patients: A retrospective cohort study

OBJECTIVES

To calculate the incidence of new-onset atrial fibrillation (NOAF) in myocardial infarction (MI) patients and examine associated predictors and clinical outcomes of NOAF patients.

METHODS

A retrospective cohort study was used to carry out this study. All MI patients admitted to King Khaled University Hospital, Riyadh, Saudi Arabia, between January 2015 to 2020 were eligible for inclusion. The study excluded those with a previous diagnosis of atrial fibrillation and patients who died at presentation.

RESULTS

A total of 281 patients were analyzed with a mean age of 58.7±12.7. Incidence of NOAF was 7.8%. Significant predictors identified by multivariate logistic regression analysis included older age (p=0.004), history of MI (p=0.012), and undergoing coronary artery bypass graft surgery (CABG) as treatment (p=0.016). New-onset atrial fibrillation was associated with higher odds of major adverse cardiovascular event (p=0.039), ventricular tachycardia (p=0.001), and mortality (p=0.031).

CONCLUSION

New-onset atrial fibrillation is a relatively common complication of MI, and in our study, it was associated with higher odds of further complications including death. Therefore, identification of MI patients at risk of developing NOAF is crucial. Our study suggests that older age, a previous history of MI, and undergoing CABG are significant predictors of NOAF development.

The effect of apolipoprotein E gene polymorphism and Lp(a) levels on coronary artery disease with atrial fibrillation

Objective

To explore the influence of apolipoprotein E (APOE) genotypes and blood lipid metabolism on coronary artery disease (CAD) with atrial fibrillation (AF).

Methods

Patients with suspected CAD were consecutively enrolled and divided into groups with or without CAD and/or AF. Blood lipid levels and APOE genotypes were determined and analysed for associations with CAD and AF.

Results

A total of 2048 patients were included (400 patients without CAD or AF [controls], 126 patients without CAD but with AF, 1294 patients with CAD without AF, and 228 patients with CAD and AF). Age and lipoprotein (a) (Lp[a]) levels were significantly higher in patients with CAD and AF versus those with CAD without AF. Among patients with CAD, the E3/E3 genotype and ε3 allele frequencies were significantly lower in patients with AF than in those without AF, and the E4/E4 genotype and ε4 allele frequencies were significantly increased. Multivariate logistic regression revealed that increased Lp(a) levels and age were independent risk factors for AF in patients with CAD.

Conclusion

Among patients with CAD, those with AF had increased age, ε4 frequencies and Lp(a) levels. Age and Lp(a) levels may be independent risk factors for AF in patients with CAD.

The Association between the PRECISE-DAPT Score and New-Onset Atrial Fibrillation in Patients with ST-Elevation Myocardial Infarction

Background: Atrial fibrillation (AF) is associated with increased morbidity in myocardial infarction (MI), especially thromboembolic risk increases. The PRECISE-DAPT (The PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti-Platelet Therapy) score was created to predict the bleeding risk of dual antiplatelet therapy. The purpose of this study was to evaluate the association between new-onset AF and the PRECISE-DAPT score in ST-segment-elevation myocardial infarction (STEMI).

Methods: This retrospective study enrolled patients who developed STEMI within 12 hours of the onset of symptoms and underwent primary percutaneous coronary intervention. The study population was divided into 2 groups of PRECISE-DAPT scores of 25 or greater and PRECISE-DAPT scores of below 25 and their baseline characteristics, as well as laboratory and echocardiography results, were compared. In-hospital new AF and related events were compared between the 2 PRECISE-DAPT score groups.

Results: From February 2015 to December 2017, this study enrolled 2234 patients with STEMI at a mean age of 54.4 years. The new-onset AF incidence rate was higher in the higher PRECISE-DAPT group than in the lower PRECISE-DAPT group (62 [28.7 %] vs 58 [2.9%]; P<0.001). According to the multivariate logistic regression analysis, the factors associated with new-onset AF were the left atrial diameter (OR=1.98, 95% confidence interval=1.34–2.93; P=0.001) and the PRECISE-DAPT score (OR=1.04, 95% confidence interval=1.10–1.18; P<0.001).

Conclusion: The PRECISE-DAPT score was associated with the development of new-onset AF in our patients with STEMI. Further follow-up of these patients will provide clearer information.

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.

Atrial Fibrillation With Decompensated Heart Failure Complicated With Non-ST Elevation Myocardial Infarction

Non-ST-elevation myocardial infarction (NSTEMI) has a less severe ratio of acute coronary syndromes compared with ST-segment elevation myocardial infarction (STEMI), arising from complete occlusion of a major coronary artery. The name implies a syndrome that does not exhibit the dramatic ST-elevation seen in the traditional 12-lead ECG in chest pain patients with a confirmed diagnosis of STEMI. The crucial clinical significance of NSTEMI is that delay in diagnosis can lead to increased morbidity, risk of arrhythmia, and death. It was recently reported that atrial fibrillation (AF) correlates with the risk rise of myocardial infarction (MI), although the mechanism underlying this association is currently unknown. Does atrial fibrillation with decompensated heart failure (DHF) get complicated with NSTEMI? In this article, we describe the case of a 77-year-old male patient diagnosed and admitted as NSTEMI complicated by DHF.

Combination of Atrial Fibrillation and Coronary Heart Disease in Patients in Clinical Practice: Comorbidities, Pharmacotherapy and Outcomes (Data from the REСVASA Registries)

Aim. Assess the structure of comorbid conditions, cardiovascular pharmacotherapy and outcomes in patients with atrial fibrillation (AF) and concomitant coronary artery disease (CAD) included in the outpatient and hospital RECVASA registries.

Materials and methods. 3169 patients with AF were enrolled in outpatient RECVASA (Ryazan), RECVASA AF-Yaroslavl registries and hospital RECVASA AF (Moscow, Kursk, Tula). 2497 (78.8%) registries of patients with AF had CAD and 703 (28.2%) of them had a previous myocardial infarction (MI).

Results. There were 2,497 patients with a combination of AF and CAD (age was 72.2±9.9 years; 43.1% of men; CHA2DS2-VASc – 4.57±1.61 points; HAS-BLED – 1.60±0,75 points), and the group with AF without CAD included 672 patients (age was 66.0±12.3 years; 43.2% of men; CHA2DS2-VASc – 3.26±1.67 points; HAS-BLED – 1,11±0.74 points). Patients with CAD were on average 6.2 years older and had a higher risk of thromboembolic and hemorrhagic complications (p<0.05). 703 patients with a combination of AF and CAD had the previous myocardial infarction (MI; age was 72.3±9.5 years; 55.2% of men; CHA2DS2-VASc – 4.57±1.61; HAS-BLED – 1.65±0.76), and 1794 patients didn't have previous MI (age was 72.2±10.0 years; 38.4% of men; CHA2DS2-VASc – 4.30±1.50; HAS-BLED – 1.58±0.78). The proportion of men was 1.4 times higher among those with the previous MI. Patients with a combination of AF and CAD significantly more often (p <0.0001) than in the absence of CAD received a diagnosis of hypertension (93.8% and 78.6%), chronic heart failure (90.1% and 51.2%), diabetes mellitus (21.4% and 13.8%), chronic kidney disease (24.8% and 17.7%), as well as anemia (7.0% and 3.0%; p=0.001). Patients with and without the previous MI had the only significant difference in the form of a diabetes mellitus higher incidence having the previous MI (27% versus 19.2%, p=0.0008). The frequency of proper cardiovascular pharmacotherapy was insufficient, mainly in the presence of CAD (67.8%) than in its absence (74.5%), especially the prescription of anticoagulants (39.1% and 66.2%; p <0.0001), as well as in the presence of the previous MI (63.3%) than in its absence (74.3%). The presence of CAD and, in particular, the previous MI, was significantly associated with a higher risk of death (risk ratio [RR]=1.58; 95% confidence interval [CI] was 1.33-1.88; p <0.001 and RR=1.59; 95% CI was 1.33-1.90; p <0.001), as well as with a higher risk of developing a combined cardiovascular endpoint (RR=1.88; 95% CI was 1.17-3 , 00; p <0.001 and RR=1.75; 95% CI was 1.44-2.12; p<0.001, respectively).

Conclusion. 78.8% of patients from AF registries in 5 regions of Russia were diagnosed with CAD, of which 28.2% had previously suffered myocardial infarction. Patients with a combination of AF and CAD more often than in the absence of CAD had hypertension, chronic heart failure, diabetes, chronic kidney disease and anemia. Patients with the previous MI had higher incidence of diabetes than those without the previous MI. The frequency of proper cardiovascular pharmacotherapy was insufficient, and to a greater extent in the presence of CAD and the previous MI than in their absence. All-cause mortality was recorded in patients with a combination of AF and CAD more often than in the absence of CAD. All-cause mortality and the incidence of nonfatal myocardial infarction were higher in patients with AF and the previous MI than in those without the previous MI. The presence of CAD and, in particular, the previous MI, was significantly associated with a higher risk of death, as well as a higher risk of developing a combined cardiovascular endpoint.

Impact of frailty and atrial fibrillation in elderly patients with acute coronary syndromes

BACKGROUND

There is scarce information on the prognostic role of frailty and atrial fibrillation (AF) in elderly patients with acute coronary syndrome (ACS).

METHODS

The aim was to analyse the management of elderly patients with frailty and AF who suffered an ACS using data of the prospective multicentre LONGEVO-SCA registry. We evaluated the predictive performance of FRAIL, Charlson scores and AF status for adverse events at 6-month follow-up.

RESULTS

A total of 531 unselected patients with ACS and above 80 years old [mean age 84.4 (SD = 3.6) years; 322 (60.6%) male] were enrolled, of whom 128 (24.1%) with AF and 145 (27.3%) with frailty. Mutually exclusive number of patients were as follows: non-frail and sinus rhythm (SR) 304 (57.2%); frail and SR 99 (18.6%); non-frail and AF 82 (15.4%); and frail and AF 46 (8.7%). Frail and AF patients compared with non-frail and SR patients had higher risk of all-cause mortality [HR 2.61, (95% CI 1.28-5.31; P = .008)], readmissions [HR 2.28, (95%CI 1.37-3.80); P = .002)] and its composite [HR 2.28, (95% CI 1.44-3.60); P < .001)]. After multivariate adjustment, FRAIL score [HR 1.41, (95% CI 1.02-1.97); P = .040] and Charlson index [HR 1.32, (95% CI 1.09-1.59); P = .003] were significantly associated with mortality. AF status was not independently related with adverse events.

CONCLUSIONS

Frailty but not AF status was independently associated with follow-up adverse events. Frailty status and high Charlson index were independent conditions associated with adverse events during the follow-up. The impact of functional status has a bigger prognostic role over AF status in elderly patients with ACS.

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.

Outcomes in patients with acute myocardial infarction and new atrial fibrillation: a nationwide analysis

BACKGROUND

In patients with acute myocardial infarction (AMI), history of atrial fibrillation (AF) and new onset AF during the early phase may be associated with a worse prognosis. Whether both conditions are associated with similar outcomes is a matter of debate.

METHODS

We collected information for all patients with AMI seen in French hospitals between 2010 and 2019. Among 797,212 patients seen with STEMI or NSTEMI, 75,701 (9.5%) had history of AF, and 34,768 (4.4%) had new AF diagnosed between day 1 and day 30 after AMI.

RESULTS

Patients with new AF were older and had more comorbidities than those with no AF but were younger and had less comorbidities than those with history of AF. During follow-up [mean (SD) 1.8 (2.4) years, median (interquartile range) 0.7 (0.1-3.1) years], 163,845 deaths and 30,672 ischemic strokes were recorded. Using Cox multivariable analysis, compared to patients with no AF, history of AF was associated with a higher risk of death during follow-up (adjusted hazard ratio HR 1.17, 95% CI 1.16-1.19) and this was also the case for patients with new AF (adjusted HR 2.11, 2.07-2.15). Both history of AF and new AF were associated with a higher risk of ischemic stroke compared to patients with no AF: adjusted HR 1.19 (1.15-1.23) for history of AF, adjusted HR 1.78 (1.68-1.88) for new AF. New AF was associated with a higher risk of death and of ischemic stroke than history of AF: adjusted HR 1.74 (1.70-1.79) and 1.32 (1.23-1.42), respectively.

CONCLUSIONS

In a large and systematic nationwide analysis, AF first recorded in the first 30 days after AMI was independently associated with higher risks of death and ischemic stroke than those in patients with no AF or previously known AF.

The Multifaceted Interplay between Atrial Fibrillation and Myocardial Infarction: A Review

This review was conducted to emphasize the complex interplay between atrial fibrillation (AF) and myocardial infraction (MI). In type 1 (T1) MI, AF is frequent and associated with excess mortality. Moreover, AF after hospital discharge for T1MI is not rare, suggesting the need to improve AF screening and to develop therapeutic strategies for AF recurrence. Additionally, AF is a common trigger for type 2 MI (T2MI), and recent data have shown that tachyarrhythmia or bradyarrhythmia could be a causal factor in, respectively, 13–47% or 2–7% of T2MI. In addition, AF is involved in T2MI pathogenesis as a result of severe anemia related to anticoagulants. AF is also an underestimated and frequent cause of coronary artery embolism (CE), as a situation at risk of myocardial infarction with non-obstructive coronary arteries. AF-causing CE is difficult to diagnose and requires specific management. Moreover, patients with both AF and chronic coronary syndromes represent a therapeutic challenge because the treatment of AF include anticoagulation, depending on the embolic risk, and ischemic heart disease management paradoxically includes antiplatelet therapy.

Trends in Short- and Long-Term ST-Segment-Elevation Myocardial Infarction Prognosis Over 3 Decades: A Mediterranean Population-Based ST-Segment-Elevation Myocardial Infarction Registry

Background Coronary artery disease remains a major cause of death despite better outcomes of ST-segment-elevation myocardial infarction (STEMI). We aimed to analyze data from the Ruti-STEMI registry of in-hospital, 28-day, and 1-year events in patients with STEMI over the past 3 decades in Catalonia, Spain, to assess trends in STEMI prognosis. Methods and Results Between February 1989 and December 2017, a total of 7589 patients with STEMI were admitted consecutively. Patients were grouped into 5 periods: 1989 to 1994 (period 1), 1995 to 1999 (period 2), 2000 to 2004 (period 3), 2005 to 2009 (period 4), and 2010 to 2017 (period 5). We used Cox regression to compare 28-day and 1-year STEMI mortality and in-hospital complication trends across these periods. Mean patient age was 61.6±12.6 years, and 79.3% were men. The 28-day all-cause mortality declined from period 1 to period 5 (10.4% versus 6.0%; P<0.001), with a 40% reduction after multivariable adjustment (hazard ratio [HR], 0.6; 95% CI, 0.46-0.80; P<0.001). One-year all-cause mortality declined from period 1 to period 5 (11.7% versus 9.0%; P=0.001), with a 24% reduction after multivariable adjustment (HR, 0.76; 95% CI, 0.60-0.98; P=0.036). A significant temporal reduction was observed for in-hospital complications including postinfarct angina (-78%), ventricular tachycardia (-57%), right ventricular dysfunction (-48%), atrioventricular block (-45%), pericarditis (-63%), and free wall rupture (-53%). Primary ventricular fibrillation showed no significant downslope trend. Conclusions In-hospital STEMI complications and 28-day and 1-year mortality rates have dropped markedly in the past 30 years. Reducing ischemia-driven primary ventricular fibrillation remains a major challenge.

Percutaneous Ventricular Assist Device vs. Intra-Aortic Balloon Pump for Hemodynamic Support in Acute Myocardial Infarction-Related Cardiogenic Shock and Coexistent Atrial Fibrillation: A Nationwide Propensity-Matched Analysis'

BACKGROUND

Patients suffering an acute myocardial infarction complicated by cardiogenic shock (AMICS) may experience clinical deterioration with concomitant atrial fibrillation (AF). Recent data suggest that percutaneous ventricular assist devices (pVADs) provide superior hemodynamic support over intra-aortic balloon pump (IABP) in AMICS. In patients with AF+AMICS, however, outcomes data comparing these two devices remain limited.

METHODS

Using the National Inpatient Sample datasets (2008-2014) and a propensity-score matched analysis, we compared the outcomes of AMICS+AF hospitalized patients undergoing PCI with pVAD vs. IABP support.

RESULTS

A total of 12,842 AMICS+AF patients were identified (pVAD=468, IABP=12,374). The matched groups (pVAD=443, IABP=443) were comparable in terms of mean age (70.3 ± 12.0 vs. 70.4 ± 11.0yrs, p = 0.92). The utilization of pVAD was higher in whites but lower in Medicare/Medicaid beneficiaries as compared to IABP. The pVAD group demonstrated higher rates of obesity (13.6% vs. 7.8%, p = 0.006) and dyslipidemia (48.4% vs. 41.8%, p = 0.05). There was no difference in the in-hospital mortality (40.5% vs. 36.8%, p = 0.25); however, pVAD group had a lower incidence of post-procedural MI and higher incidences of stroke (7.8% vs. 4.4%, p = 0.03), hemorrhage (5.6% vs. 2.3%, p = 0.01), discharges to home health care (13.5% vs. 10.1%, p<0.001) and to other facilities (29.1% vs. 24.9%, p<0.001) as compared to IABP group. There was no difference between the groups in terms of mean length of stay or hospital charges.

CONCLUSIONS

All-cause inpatient mortality was similar in AMICS+AF patients undergoing PCI who were treated with either pVAD or IABP. The pVAD group, however, experienced more complications while consuming greater healthcare resources.

Effect of 2 Different Dosages of Rosuvastatin on Prognosis of Acute Myocardial Infarction Patients with New-Onset Atrial Fibrillation in Jinan, China

BACKGROUND Atrial fibrillation (AF) often occurs in patients with acute myocardial infarction (AMI). This study aimed to observe the influence of different dosages of rosuvastatin on the prognosis of AMI patients with AF. MATERIAL AND METHODS We performed an observational, retrospective cohort study in Jinan, China, in which 323 AMI patients were recruited. All patients were randomized to receive optimal medication treatment and 10 mg or 20 mg of rosuvastatin. Holter monitor results, serum lipid levels, and heart function were recorded. We used multivariate Cox and Kaplan-Meier analyses to assess the independent factors and differences in AF and ischemia events and safety of rosuvastatin administered at different dosages. RESULTS TC, LDL-C, and TG at 1 and 12 months were significantly lower compared with those observed prior to treatment in both groups. The heart function of both groups was significantly improved after 12 months of treatment, especially in the 20 mg group. Multivariate Cox analysis showed that different dosages of rosuvastatin, age, smoking, drinking alcohol, and diabetes are independent factors related to the occurrence of AF and ischemic events. In addition, according to Kaplan-Meier analysis, no significant difference in adverse clinical events existed at different dosages of rosuvastatin. CONCLUSIONS Treatment with rosuvastatin can reduce the serum lipid level and improve cardiac function. Different dosages of rosuvastatin, age, smoking, drinking alcohol, and diabetes are independent risk factors for AF and ischemia events. The results suggested it is safe to use 20 mg rosuvastatin in the 12 months after hospital admission.

Burden of Arrhythmias in Acute Myocardial Infarction Complicated by Cardiogenic Shock

There are limited data on arrhythmias in acute myocardial infarction with cardiogenic shock (AMI-CS). Using a 17-year AMI-CS population from the National Inpatient Sample, we identified common arrhythmias - atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrioventricular blocks (AVB). Admissions with concomitant cardiac surgery were excluded. Outcomes of interest included temporal trends, predictors, in-hospital mortality, and resource utilization in cohorts with and without arrhythmias. Of the 420,319 admissions with AMI-CS during 2000 to 2016, arrhythmias were noted in 213,718 (51%). AF (45%), ventricular tachycardia (35%) and ventricular fibrillation (30%) were the most common arrhythmias. Compared with those without, the cohort w`ith arrhythmias was more often male, of white race, with ST-segment elevation AMI-CS presentation, and had higher rates of cardiac arrest and acute organ failure (all p <0.001). Temporal trends of prevalence revealed a stable trend of atrial and ventricular arrhythmias and declining trend in AVB. The cohort with arrhythmias had higher unadjusted (42% vs 41%; odds ratio [OR] 1.03 [95% confidence interval 1.02 to 1.05]; p <0.001), but not adjusted (OR 1.01 [95% CI 0.99 to 1.03]; p = 0.22) in-hospital mortality compared with those without. The cohort with arrhythmias had longer hospital stay (9 ± 10 vs 7 ± 9 days; p <0.001) and higher hospitalization costs ($124,000 ± 146,000 vs $91,000 ± 115,000; p <0.001). In the cohort with arrhythmias, older age, female sex, non-white race, higher co-morbidity, presence of acute organ failure, and cardiac arrest, predicted higher in-hospital mortality. In conclusion, cardiac arrhythmias in AMI-CS are a marker of higher illness severity and are associated with greater resource utilization.

Management of Common Cardiovascular Emergencies in Critically Ill Patients

This article reviews treatment and management of common cardiovascular emergencies in critically ill patients, focusing on acute decompensated heart failure, cardiogenic shock, pulmonary embolism, and hypertensive crisis management with inotropes, vasopressors, diuretics, and antiarrhythmic drugs. Clinicians frequently come across challenging clinical scenarios, and there is a gap between evidence-based medicine and clinical practice. Inotropic and vasopressor agents are useful in the acute setting but must be weaned off or used as a bridge for mechanical circulation support devices. Clinicians should aim to lower complications by choosing medications with respect to comorbidities and close the gap between evidence-based medicine and clinical practice.

[Risk of Coronary Events in Atrial Fibrillation]

It has been established that cardiovascular events due to coronary heart disease are highly prevalent in the population of patients with atrial fibrillation. In this review, pathophysiologic mechanisms explaining this association are detailed along with supporting epidemiological evidence. Various methods for the prediction and prevention of coronary events in atrial fibrillation are iscussed, including modification of shared risk factors, antithrombotic therapy and selection of the optimal direct oral anticoagulant in terms of favourable influence on ischemic cardiac outcomes.

The influence of atrial fibrillation on the mortality of incident ESRD patients undergoing maintenance hemodialysis

Background

Atrial fibrillation (AF) is highly prevalent, occurring in 1%–2% of the adult population, increasing the risk of stroke, and resulting in considerable healthcare costs. While stroke is a major complication of AF, end-stage renal disease (ESRD) patients also have a high risk of stroke, suggesting that AF is a possible risk factor for mortality of ESRD patients. However, whether the existence of AF at the initiation of hemodialysis predicts higher mortality risk of incident ESRD patients remains to be defined.

Methods

This retrospective cohort study was performed at Wanfang Hospital from January 2004 to May 2018. The end points were mortality of patients or the end of the study. Incident ESRD patients who were on maintenance hemodialysis for more than 3 months were eligible for inclusion. Cox proportional regression and Kaplan–Meier survival curves were used to determine the association between predictors and mortality. The association between AF and echocardiographic parameters, causes of death were also investigated.

Results

Of the 393 incident ESRD patients at initiation of hemodialysis, 57 (14.5%) had AF and the median age was 71 years. Patients with AF were significantly older; showed significantly higher C-reactive protein levels, more heart failure, chronic obstructive pulmonary disease and mortality. Multivariate Cox regression showed that AF had a hazard ratio of 4.1 (95% confidence interval: 2.4–7.0) for mortality. Age-specific analysis showed that AF was significantly associated with mortality in all age groups. Echocardiography measurements including ejection fraction and left ventricular hypertrophy (LVH) were similar in AF and non-AF patients. Cause-specific analysis showed that AF significantly associated with overall cardiovascular death and death due to acute myocardial infarction/coronary artery disease and sepsis.

Conclusions

AF at the initiation of hemodialysis predicts higher mortality risk of incident ESRD patients regardless of age. The systolic function and degree of LVH were similar in AF and non-AF patients. The association between AF and sepsis-related death suggested the role of systemic inflammation on the pathogenesis of AF.

Correlation between HCN4 gene polymorphisms and lone atrial fibrillation risk

Background and objective: Atrial electrical remodelling (AER) was significantly associated with atrial fibrillation (AF) development. Polymorphisms in hyperpolarization activated cyclic nucleotide gated potassium channel 4 (HCN4) gene might be correlated with AER. In the present study, we explored the association of HCN4 polymorphisms (rs498005 and rs7164883) with lone AF risk in a Chinese Han population. Methods: In this case-control study, the Sanger sequencing method was utilized to genotype the HCN4 polymorphisms. Relative risk of AF was assessed by the χ² test, and presented by odds ratios (ORs) and corresponding 95% confidence intervals (CIs). Logistic regression analysis was performed for multivariate analysis. The effects of HCN4 polymorphisms on AF clinical features were analyzed by the Mann-Whitney U test and adjusted by the Bonferroni method. Results: C allele of rs498005 was significantly correlated with increased risk of AF (OR = 1.412, 95%CI = 1.012-1.970), and the association still exited after adjustment by age, gender, the status of smoking and drinking, histories of diabetes, hyperlipidaemia and myocardial infarction (adjusted OR = 1.473, 95%CI = 1.043-2.081). G allele of rs7164883 SNP was marginally associated with enhanced AF risk after adjustment by the above clinical parameters (adjusted OR = 1.742, 95%CI = 1.019-2.980). Atrial late potential (ALP), including TP (P wave duration after filtering) and LP₂₀ (the amplitude of superimposed potential in the final 20 ms of P wave) were significantly associated with rs498005 genotype (p < .001). Conclusion: HCN4 rs498005 and rs7164883 polymorphisms are significantly associated with AF risk.

[Specific Features of the Course of Acute Coronary Syndrome in Patients with Newly Developed Atrial Fibrillation in Clinical Practice According to the Data of the Register of Acute Coronary Syndrome]

AIM

to elucidate risk factors of development of atrial fibrillation (AF) in patients with acute coronary syndrome (ACS), and to assess of patient's adherence to oral anticoagulant therapy (OAT) during 12 months after ACS episode according to the data of the Total ACS Registry for the Krasnodar Territory.

MATERIALS AND METHODS

In this retrospective analysis we used Registry data on patients with ACS and concomitant AF, consecutively admitted to cardiological departments of the S.V. Ochapovsky Territorial Clinical Hospital from 20/11/2015 to 20/02/18. Number of patients in the analyzed group was 201 (52 with AF which first appeared in connection with the index ACS). Survivors after hospital discharge were contacted by telephone and at planned visits. The analysis included assessment of rates of the following outcomes: inhospital death, hemorrhagic and thromboembolic complications, prognostic efficacy of the CRISADE and HAS BLED scores, and expediency of prescription to patients with ACS and concomitant first AF episode of prolonged OAT after hospital discharge.

RESULTS

Demographic and anamnestic data of patients with the first AF attack at the background of ACS were like those of patients with other types of AF. This group of patients was characterized by more severe course of the disease, but this produced no impact on inhospital mortality and rate of complications, as well as on mortality for 12 months after hospital discharge.

CONCLUSION

The results of this analysis are important for understanding distinctive characteristics of patients with AF first developed during ACS.

Sex-differences in post-discharge outcomes among patients hospitalized for atrial fibrillation

BACKGROUND

Patients with atrial fibrillation (AF) are at risk for both thromboembolic and bleeding complications. While the risk for thromboembolism is higher among women with AF than men, the sex-related differences in post-discharge outcomes after hospitalization is not clearly understood.

HYPOTHESIS

Compared to men, women hospitalized for AF are at a higher risk of both thromboembolic and bleeding complications.

METHODS

We conducted a retrospective cohort study using data from the 2013 to 2014 Nationwide Readmission Database (NRD), to compare outcomes among men and women, ≥50 years of age after hospitalization for AF. The primary patient outcome was all-cause rehospitalization at 90-days after initial hospitalization. Survey-weighted Cox proportional hazard regression models were used to estimate the hazard ratios (HR) and their 95% confidence intervals (CI) for bleeding events at 30, 60, 90, and 270 days after hospitalization.

RESULTS

From the 28 million patients in the NRD, we identified 522 521 individuals with an index hospitalization for AF. Compared to men, women hospitalized for AF accounted for 53.3% of the cohort and had higher rates of thrombotic (1.7%, 1.4%) and bleeding complications (1.4%, 1.1%). After adjustment, the 90-day risk among women vs men was significantly greater; all-cause rehospitalization (24.2%, 17.0%; HR = 1.07, 95% CI = 1.05-1.09), rehospitalization related to ischemic stroke (0.6%, 0.3%; HR 1.31, 95% CI = 1.14-1.51), pulmonary embolism (0.4%, 0.2%; HR 1.21, 95% CI = 1.01-1.45), and any thrombotic event (1.3%, 0.7%; HR 1.20, 95% CI = 1.09-1.32).

CONCLUSIONS

Hospitalization for AF is common and frequently associated with both in-hospital complications and readmission, which were more commonly observed among women with AF. Further research into epidemiological factors and treatment differences between men and women with AF is warranted.

Previous and New Onset Atrial Fibrillation and Associated Outcomes in Acute Coronary Syndromes (from the Global Registry of Acute Coronary Events)

Atrial fibrillation (AF) is a frequent complication of acute coronary syndromes (ACS) and is associated with an increased risk of in-hospital and long-term mortality. Our objective was to determine whether patients with previous AF and those who presented with or developed AF during their ACS hospitalization (new onset) have an associated increased risk of short- and mid-term cardiovascular events, death, or a composite. We included 7,228 patients from the Global Registry of Acute Coronary Events electrocardiogram core laboratory substudy, who presented with an ACS. Associated multivariable-adjusted risk of death and major adverse cardiovascular events (MACE) of death, re-infarction, or stroke in-hospital and at 6 months were estimated. New-onset AF and previous AF patients had higher rates of in-hospital mortality (14.9% and 10.9%, respectively) compared with patients without AF (3.8%; both p < 0.001). New-onset AF and previous AF patients had higher rates of 6-month mortality (22.3% and 21.3%, respectively) compared with patients without AF (7.0%; both p <0.001). After adjustment for clinical prognosticators, including those in the Global Registry of Acute Coronary Events risk model, new-onset AF was associated with higher mortality in-hospital (OR_adj 1.87, 95% CI 1.30 to 2.70) and at 6 months (OR_adj 1.75, 95% CI 1.29 to 2.39) as well as MACE at 6 months (OR_adj 1.43, 95% CI 1.12 to 1.81) compared with patients without AF, but were at similar risk compared to those with previous AF (all p > 0.40). In conclusion, the risk of death and MACE after ACS in patients with new-onset and previous AF appears similar and significantly increased compared with patients without AF.

Risk evaluation of new-onset atrial fibrillation complicating ST-segment elevation myocardial infarction: a comparison between GRACE and CHA2DS2-VASc scores

Purpose

New-onset atrial fibrillation (NOAF) is a common finding in patients with myocardial infarction (MI), but few studies are available regarding the prediction model for its risk estimation. Although Global Registry of Acute Coronary Events (GRACE) risk score (RS) has been recognized as an effective tool for the risk evaluation of clinical outcomes in patients with MI, its usefulness in the prediction of post-MI NOAF remains unclear. In this study, we sought to validate the discrimination performance of GRACE RS in the prediction of post-MI NOAF and to make a comparison with that of the CHA₂DS₂-VASc score in patients with ST-segment elevation myocardial infarction (STEMI).

Patients and methods

A total of 488 patients with STEMI who were admitted to our hospital between May 2015 and October 2016 without a history of atrial fibrillation were retrospectively evaluated in this study. GRACE and CHA₂DS₂-VASc scores were calculated for each patient. Patients were divided into low (GRACE RS≤125)-, intermediate (GRACE RS 126–154)-, and high (GRACE RS≥155)-risk groups. Receiver operating characteristic curve analyses were performed to evaluate the discrimination performance of both RSs. Model calibration was evaluated by using Hosmer–Lemeshow goodness-of-fit test (HLS).

Results

Of the 488 eligible patients, 49 (10.0%) developed NOAF during hospitalization. In the overall cohort, the discrimination performance of GRACE RS (C-statistic: 0.76, 95% CI: 0.72–0.80) was significantly better than that of CHA₂DS₂-VASc score (C-statistic: 0.68, 95% CI: 0.64–0.72; comparison p=0.03). For subgroup analysis, GRACE RS tended to be better than the CHA₂DS₂-VASc score in all but the intermediate-risk group as evidenced by C-statistics of 0.60 and 0.65 for GRACE and CHA₂DS₂-VASc scores, respectively. Excellent calibration was achieved except for GRACE RS in females (HLS p=0.05).

Conclusion

The diagnostic performance of GRACE RS is relatively high as well as better than that of the CHA₂DS₂-VASc score with respect to the prediction of post-MI NOAF.

Long-Term Outcomes of Acute Myocardial Infarction in Patients With Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is associated with poor prognosis. It has been reported that there is no difference in in-hospital mortality after acute myocardial infarction (AMI) between patients with and without HCM. However, whether there are differences in long-term outcomes after AMI between patients with and without HCM remains unclear. In this study, we analyzed the clinical profiles of 78 consecutive patients with HCM and AMI (HCM and AMI group), 78 sex- and age-matched patients with AMI and without HCM (AMI group), and 78 sex- and age-matched patients with HCM and without AMI (HCM group). The study end points were major adverse cardiac events (MACEs) and secondary end points. During the follow-up period of 4.8 ± 3.6 years, MACEs occurred in 19 (27.9) patients in the HCM and AMI group, in 11 (16.7%) patients in the AMI group, and in 8 (12.3%) patients in the HCM group. The long-term outcomes of the HCM and AMI group were inferior to that of the other 2 groups (log-rank P = .030 for MACEs, log-rank P = .032 for secondary end points). In conclusion, patients with AMI with HCM exhibited worse long-term outcomes than did patients with AMI without HCM and patients with HCM without AMI.

Recent Trends in Oral Anticoagulant Use and Post-Discharge Complications Among Atrial Fibrillation Patients with Acute Myocardial Infarction

BACKGROUND

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI).The CHA2DS2VAScand CHADS2risk scoresare used to identifypatients with AF at risk for strokeand to guide oral anticoagulants (OAC) use, including patients with AMI. However, the epidemiology of AF, further stratifiedaccording to patients' risk of stroke, has not been wellcharacterized among those hospitalized for AMI.

METHODS

We examined trends in the frequency of AF, rates of discharge OAC use, and post-discharge outcomes among 6,627 residents of the Worcester, Massachusetts area who survived hospitalization for AMI at 11 medical centers between 1997 and 2011.

RESULTS

A total of 1,050AMI patients had AF (16%) andthe majority (91%)had a CHA2DS2VAScscore >2.AF rates were highest among patients in the highest stroke risk group.In comparison to patients without AF, patients with AMI and AF in the highest stroke risk category had higher rates of post-discharge complications, including higher 30-day re-hospitalization [27 % vs. 17 %], 30-day post-discharge death [10 % vs. 5%], and 1-year post-discharge death [46 % vs. 18 %] (p < 0.001 for all). Notably, fewerthan half of guideline-eligible AF patientsreceived an OACprescription at discharge. Usage rates for other evidence-based therapiessuch as statins and beta-blockers,lagged in comparison to AMI patients free from AF.

CONCLUSIONS

Our findings highlight the need to enhance efforts towards stroke prevention among AMI survivors with AF.

Mortality and Atrial Fibrillation in the FIACA Study: Evidence of a Differential Effect According to Admission Diagnosis

INTRODUCTION AND OBJECTIVES

Atrial fibrillation (AF) is an independent risk factor for mortality in several diseases. However, data published in acute decompensated heart failure (DHF) are contradictory. Our objective was to investigate the impact of AF on mortality in patients admitted to hospital for DHF compared with those admitted for other reasons.

METHODS

This retrospective cohort study included all patients admitted to hospital within a 10-year period due to DHF, acute myocardial infarction (AMI), or ischemic stroke (IS), with a median follow-up of 6.2 years.

RESULTS

We included 6613 patients (74 ± 11 years; 54.6% male); 2177 with AMI, 2208 with DHF, and 2228 with IS. Crude postdischarge mortality was higher in patients with AF hospitalized for AMI (incident rate ratio, 2.48; P < .001) and IS (incident rate ratio, 1.84; P < .001) than in those without AF. No differences were found in patients with DHF (incident rate ratio, 0.90; P = .12). In adjusted models, AF was not an independent predictor of in-hospital mortality by clinical diagnosis. However, AF emerged as an independent predictor of postdischarge mortality in patients with AMI (HR, 1.494; P = .001) and IS (HR, 1.426; P < .001), but not in patients admitted for DHF (HR, 0.964; P = .603).

CONCLUSIONS

AF was as an independent risk factor for postdischarge mortality in patients admitted to hospital for AMI and IS but not in those admitted for DHF.

Predictions and Outcomes of Atrial Fibrillation in the Patients with Acute Myocardial Infarction

The large epidemiological studies demonstrated that atrial fibrillation is correlated with high mortality and adverse events in patients with acute myocardial infarction. The aim of this study was to determinate predictors of atrial fibrillation develop during the hospital period in patients with acute myocardial infarction as well as short- and long-term mortality depending on the atrial fibrillation presentation. The 600 patients with an acute myocardial infarction were included in the study and follow-up 84 months. Atrial fibrillation develops during the hospital period was registered in 48 patients (8%). After adjustment by logistic regression model the strongest predictor of atrial fibrillation develop during the hospital period was older age, particularly more than 70 years (odds ratio 2.37, CI 1.23-4.58, p=0.010), followed by increased of Body Mass Index (odds ratio 1.17, CI 1.04-1.33, p=0.012), enlarged diameter of left atrium (LA) (odds ratio 1,18, CI 1,03-1,33, p=0,015) presentation of mitral regurgitation (odds ratio 3.56, CI 1.25-10.32, p=0.018) and B-type natriuretic peptide (odds ratio 2.12, CI 1.24-3.33, p=0.048).Patients with atrial fibrillation develop during the hospital period had a higher mortality during the hospital course (10.4% vs. 5.6%) p=0.179. as well as follow-up period of 84 months than patients without it (64.6% vs. 39.1%) p=0.569, than patients without it, but without statistically significance. Patients with AF develop during the hospital period had higher mortality during the hospital course as well as follow up period of 84 months than patients without it, but without statistically significance.