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Herczeg S, Simon J, Szegedi N, Karády J, Kolossváry M, Szilveszter B, Balogi B, Nagy VK, Merkely B, Széplaki G, Maurovich-Horvat P, Gellér L. High incidence of newly diagnosed obstructive coronary artery disease regardless of chest pain detected on pre-procedural cardiac computed tomography angiography in patients undergoing atrial fibrillation ablation. Coron Artery Dis 2023; 34:18-23. [PMID: 36484216 PMCID: PMC9742003 DOI: 10.1097/mca.0000000000001201] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/08/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cardiac computed tomography (CT) is often performed before catheter ablation of atrial fibrillation to map atrial and pulmonary anatomy. Incident coronary artery disease (CAD) may also be diagnosed during cardiac CT angiography (CTA). Our aim was to assess whether coronary CTA might be able to identify a significant proportion of patients with obstructive CAD prior to their catheter ablation procedure event, even in asymptomatic patients. METHODS Consecutive patients undergoing pre-ablation coronary CTA for atrial fibrillation between 2013 and 2020 were retrospectively selected. Patients with previously diagnosed CAD were excluded. Obstructive CAD was defined as ≥50% luminal stenosis. We analyzed the relationship between obstructive CAD, any chest pain, and traditional risk factors. RESULTS Overall, 2321 patients [median age 63.0 (54.4-69.2), 1052/2321 (45.3%) female] underwent coronary CTA and 488/2321 (21.0%) were diagnosed with obstructive CAD. There was no difference regarding the rate of obstructive CAD in patients with any chest pain compared to patients without any chest pain [91/404 (22.5%) vs. 397/1917 (20.7%), P = 0.416, respectively). The following parameters were associated with obstructive CAD: age > 65 years [odds ratio (OR) = 2.51; 95% confidence interval (CI), 2.02-3.13; P < 0.001), male sex (OR = 1.59; 95% CI, 1.28-1.98; P < 0.001), hypertension (OR = 1.40; 95% CI, 1.08-1.81; P = 0.012), diabetes (OR = 1.50; 95% CI, 1.13-1.99; P = 0.006), dyslipidaemia (OR = 1.33; 95% CI, 1.07-1.66; P = 0.011) and history of smoking (OR = 1.34; 95% CI, 1.07-1.68; P = 0.011). CONCLUSIONS The high prevalence of obstructive CAD even in patients without chest pain highlights the importance of additional coronary artery diagnostics in patients undergoing left atrial CTA awaiting catheter ablation for atrial fibrillation. These patients regardless of chest pain thus may require further risk modification to decrease their potential ischemic and thromboembolic risk.
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Affiliation(s)
- Szilvia Herczeg
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Nándor Szegedi
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Júlia Karády
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Bernadett Balogi
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Vivien K Nagy
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
| | - Gábor Széplaki
- Atrial Fibrillation Institute, Mater Private Hospital, Dublin
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
- Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - László Gellér
- Cardiology Department, Heart and Vascular Center, Heart and Vascular Centre of Semmelweis University, Budapest, Hungary
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Cui YK, Dong JZ, Du X, Hu R, He L, Long DY, Bai R, Yu RH, Sang CH, Jiang CX, Liu N, Li SN, Wang W, Guo XY, Zhao X, Zuo S, Tang RB, Ma CS. Outcome of catheter ablation for paroxysmal atrial fibrillation in patients with stable coronary artery disease. Pacing Clin Electrophysiol 2022; 45:1032-1041. [PMID: 35866663 DOI: 10.1111/pace.14571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 04/19/2022] [Accepted: 06/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist. This study aimed to assess the long-term outcome of catheter ablation in patients with paroxysmal AF and SCAD. METHODS In total, 12104 patients with paroxysmal AF underwent catheter ablation in the Chinese Atrial Fibrillation Registry between 2011 and 2019 were screened. A total of 441 patients with SCAD were matched with patients without SCAD in a 1:4 ratio. The primary endpoint was AF recurrence after single ablation. The composite secondary endpoints were thromboembolism, coronary events, major bleeding, all-cause death. RESULTS;: Over a mean follow-up of 46.0±18.9 months, the recurrence rate in patients with SCAD was significantly higher after a single ablation (49.0% vs. 41.9%, P = 0.03). The very late recurrence rate of AF in the SCAD group was also significantly higher than that in the control group (38.9% vs. 31.2%;P = 0.04). In multivariate analysis, adjusted with the female, smoking, duration of AF, previous thromboembolism, COPD, and statins, SCAD was independently associated with AF recurrence (adjusted HR, 1.19 [1.02-1.40], P = 0.03). The composite secondary endpoints were significantly higher in the SCAD group (12.70% vs. 8.54%, P = 0.02), mainly due to thromboembolism events (8.16% vs. 4.41%, P<0.01). CONCLUSIONS SCAD significantly increased the risk of recurrence after catheter ablation of paroxysmal AF. The incidence of thromboembolic events after catheter ablation of paroxysmal AF in the patients with SCAD was significantly higher than that in those without SCAD. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yi-Kai Cui
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Rong Hu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - De-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Rong-Hui Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Chen-Xi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Song-Nan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Xue-Yuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Xin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Song Zuo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, No. 2 Beijing Anzhen Road, Chaoyang District, Beijing, 100029, China
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Cho MS, Kang DY, Oh YS, Lee CH, Choi EK, Lee JH, Kwon CH, Park GM, Park HW, Park KH, Park KM, Hwang J, Yoo KD, Cho YR, Kim YR, Hwang KW, Jin ES, Kim PJ, Kim KH, Park DW, Nam GB. Edoxaban-based long-term antithrombotic therapy in patients with atrial fibrillation and stable coronary disease: Rationale and design of the randomized EPIC-CAD trial. Am Heart J 2022; 247:123-131. [PMID: 35149036 DOI: 10.1016/j.ahj.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anticoagulants are the standard therapy for patients with atrial fibrillation (AF) and antiplatelet therapy for those with coronary artery disease (CAD). However, compelling clinical evidence is still lacking regarding the long-term maintenance strategy with the combination of anticoagulant and antiplatelet drugs in patients with AF and stable CAD. DESIGN The EPIC-CAD trial is an investigator-initiated, multicenter, open-label randomized trial comparing the safety and efficacy of 2 antithrombotic strategies in patients with high-risk AF (CHA2DS2-VASc score ≥ 2 points) and stable CAD (≥6 months after revascularization for stable angina or ≥12 months for acute coronary syndrome; or medical therapy alone). Patients (approximately N = 1,038) will be randomly assigned at a 1:1 ratio to (1) monotherapy with edoxaban (a non-vitamin K antagonist oral anticoagulant) or (2) combination therapy with edoxaban plus a single antiplatelet agent. The primary endpoint is the net composite outcome of death from any cause, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant nonmajor bleeding at 1 year after randomization. RESULTS As of December 2021, approximately 901 patients had been randomly enrolled over 2 years at 18 major cardiac centers across South Korea. The completed enrollment is expected at the mid-term of 2022, and the primary results will be available by 2023. CONCLUSIONS EPIC-CAD is a large-scale, multicenter, pragmatic design trial, which will provide valuable clinical insight into edoxaban-based long-term antithrombotic therapy in patients with high-risk AF and stable CAD.
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Nous FM, Budde RP, van Dijkman ED, Musters PJ, Nieman K, Galema TW. Prognostic Value of Subclinical Coronary Artery Disease in Atrial Fibrillation Patients Identified by Coronary Computed Tomography Angiography. Am J Cardiol 2020; 126:16-22. [PMID: 32345472 DOI: 10.1016/j.amjcard.2020.03.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 01/20/2023]
Abstract
Identifying coronary artery disease (CAD) in atrial fibrillation (AF) patients improves risk stratification and defines clinical management. However, the value of screening for subclinical CAD with cardiac CT in AF patients is unknown. Between 2011 and 2015, 94 consecutive patients without known or suspected CAD (66 (57-73) years, 68% male), who were referred for AF evaluation, underwent a noncontrast-enhanced coronary calcium scan and a coronary computed tomography angiography (CCTA) at our center. We retrospectively evaluated the coronary calcium score, the prevalence of obstructive CAD (≥50% stenosis) determined by CCTA, compared clinical management and 5-year outcome in patients with and without obstructive CAD on CCTA, and examined the potential impact of a coronary calcium score and obstructive CAD on CCTA as a manifestation of vascular disease on the CHA2Ds2VASc score and for the cardiovascular risk stratification of AF patients. The median coronary calcium score was 57 (0-275) and 24 patients (26%) had obstructive CAD on CCTA. At baseline, patients with obstructive CAD more often used statins than those without obstructive CAD (54% vs 26%, p = 0.011). After a median clinical follow-up of 2.4 (0.5-4.5) years, patients with obstructive CAD more frequently used oral anticoagulant and/or antiplatelet drugs, statins, angiotensin-II-receptor blockers and/or angiotensin-converting-enzyme inhibitors, and less often used class I antiarrhythmic drugs than patients without obstructive CAD (all p <0.050). After a median follow-up of 5.7 (4.8-6.8) years, mortality was higher in patients with obstructive CAD than in those without obstructive CAD (29% vs 11%, log-rank test: p = 0.034). Implementation of a coronary calcium score and/or obstructive CAD on CCTA elevated the CHA2Ds2VASc score and cardiovascular risk stratification in 42 patients (p <0.001) and 47 patients (p = 0.006), respectively. In conclusion, we observed a high prevalence of obstructive CAD on CCTA in AF patients without known or suspected CAD. AF patients with obstructive CAD were managed differently and had a worse prognosis than those without obstructive CAD. Cardiac CT could enhance cardiovascular risk stratification of AF patients.
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