Coronary Embolism Among Patients With ST-Segment-Elevation Myocardial Infarction and Atrial Fibrillation: An Underrecognized But Deadly Association

BACKGROUND

The prevalence and impact of coronary emboli (CE) in patients with ST-segment-elevation myocardial infarction (STEMI) and atrial fibrillation (AF) have not been specifically studied. The objective was to describe the clinical characteristics and outcomes of patients with AF and CE in a large series of patients with STEMI.

METHODS AND RESULTS

We investigated 2292 consecutive patients with STEMI and among them 225 patients with AF: 46 patients with a STEMI related to CE (group A) and 179 patients with a STEMI related to an atherosclerotic cause (group B). Compared with the 2067 patients without AF and CE (group C), patients with AF and CE were older (73 versus 59 years, P<0.05), more likely to be female (43% versus 22%, P<0.05), and presented more frequently with cardiogenic shock at admission (26% versus 9%, P<0.05). The baseline characteristics of patients with AF (group A versus B) did not differ significantly according to STEMI pathogenesis. In the unadjusted analysis, the 45-day mortality was higher in patients with CE and AF (group A versus group C: 20% versus 4%; P<0.05 and group A versus group B: 20% versus 8%, P=not significant); this trend persisted at 2-year follow-up (group A versus group C: 24% versus 6%; P<0.05 and group A versus group B: 24% versus 17%, P=not significant). After stabilized inverse exposure probability weighting adjustment, a higher 45-day mortality rate was confirmed in patients with CE and AF (group A versus group C: 18% versus 5%, P<0.05).

CONCLUSIONS

In patients presenting with STEMI and AF, CE was associated with excess early mortality.

REGISTRATION

URL: clinicaltrials.gov. Identifier: NCT05679843.

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.

Prognostic Impact of Atrial Fibrillation in Patients with Heavily Calcified Coronary Artery Disease Receiving Rotational Atherectomy

Background and Objectives: Although both rotational atherectomy (RA) and atrial fibrillation (AF) have a high thrombotic risk, there have been no previous studies on the prognostic impact of AF in patients who undergo percutaneous coronary intervention (PCI) using RA. Thus, the aim of the present study was to determine the prognostic impact of AF in patients undergoing PCI using RA. Materials and Methods: A total of 540 patients who received PCI using RA were enrolled between January 2010 and October 2019. Patients were divided into AF and sinus rhythm groups according to the presence of AF. The primary endpoint was net adverse clinical events (NACEs) defined as a composite outcome of all-cause death, myocardial infarction, target vessel revascularization, cerebrovascular accident, or total bleeding. Results: Although in-hospital adverse events showed no difference between those with AF and those without AF (in-hospital events, 54 (11.0%) vs. 6 (12.2%), p = 0.791), AF was strongly associated with an increased risk of NACE at 3 years (NACE: hazard ratio, 1.880; 95% confidence interval, 1.096-3.227; p = 0.022). Conclusions: AF in patients who underwent PCI using RA was strongly associated with poor clinical outcomes. Thus, more attention should be paid to thrombotic and bleeding risks.

The bidirectional association between atrial fibrillation and myocardial infarction

Atrial fibrillation (AF) is associated with an increased risk of myocardial infarction (MI) and vice versa. This bidirectional association relies on shared risk factors as well as on several direct and indirect mechanisms, including inflammation, atrial ischaemia, left ventricular remodelling, myocardial oxygen supply-demand mismatch and coronary artery embolism, through which one condition can predispose to the other. Patients with both AF and MI are at greater risk of stroke, heart failure and death than patients with only one of the conditions. In this Review, we describe the bidirectional association between AF and MI. We discuss the pathogenic basis of this bidirectional relationship, describe the risk of adverse outcomes when the two conditions coexist, and review current data and guidelines on the prevention and management of both conditions. We also identify important gaps in the literature and propose directions for future research on the bidirectional association between AF and MI. The Review also features a summary of methodological approaches for the study of bidirectional associations in population-based studies.

Prior statin use and the incidence of in-hospital arrhythmia in acute coronary syndrome: A systematic review and meta-analysis

BACKGROUND

The benefit of prior statin use to reduce the incidence of arrhythmia in acute coronary syndrome (ACS) is still a matter of debate. Statins have multiple pleiotropic effects, which may reduce the incidence of in-hospital arrhythmia. A systematic review and meta-analysis were performed to evaluate prior statin use and the incidence of in-hospital arrhythmia in ACS.

METHODS

This systematic review was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). We performed a literature search through Pubmed, Proquest, EBSCOhost, and Clinicaltrial.gov. A random-effect model was used due to moderate heterogeneity. Quality assessment was performed using Newcastle Ottawa Scale. Sensitivity analysis was performed by using leave one or two out method. PROSPERO registration number: CRD42022336402.

RESULTS

Nine eligible studies consisting of 86,795 patients were included. A total of 22,130 (25.5%) patients were in statin use before the index ACS event. The prevalence of old myocardial infarction, heart failure, hypertension, diabetes mellitus, and chronic renal failure and concomitant treatment with aspirin, clopidogrel, and beta blocker was higher in the prior statin group compared to no previous statin. Overall, prior statin use was associated with a significantly lower incidence of in-hospital arrhythmia during ACS compared to no previous statin (OR 0.60; 95% CI 0.49-0.72; P < 0.00001; I² = 54%, P-heterogeneity = 0.03). In subgroup analysis, previous statin use reduced the incidence of atrial fibrillation or atrial flutter (OR 0.64; 95% CI 0.43-0.95; P = 0.03; I² = 73%, P-heterogeneity = 0.01) and ventricular tachycardia or ventricular fibrillation (OR 0.57; 95% CI 0.49-0.65; P < 0.00001; I² = 8%, P-heterogeneity = 0.35).

CONCLUSIONS

Based on aggregate patient data, prior statin use may reduce the incidence of in-hospital arrhythmia during ACS, particularly atrial fibrillation or atrial flutter and ventricular tachycardia or ventricular fibrillation.

Prediction Model of New Onset Atrial Fibrillation in Patients with Acute Coronary Syndrome

OBJECTIVE

Atrial fibrillation (AF) is one of the most common complications of acute coronary syndrome (ACS) patients. Possible risk factors related to new-onset AF (NOAF) in ACS patients have been reported in some studies, and several prediction models have been established. However, the predictive power of these models was modest and lacked independent validation. The aim of this study is to define risk factors of NOAF in patients with ACS during hospitalization and to develop a prediction model and nomogram for individual risk prediction.

METHODS

Retrospective cohort studies were conducted. A total of 1535 eligible ACS patients from one hospital were recruited for model development. External validation was performed using an external cohort of 1635 ACS patients from another hospital. The prediction model was created using multivariable logistic regression and validated in an external cohort. The discrimination, calibration, and clinical utility of the model were evaluated, and a nomogram was constructed. A subgroup analysis was performed for unstable angina (UA) patients.

RESULTS

During hospitalization, the incidence of NOAF was 8.21% and 6.12% in the training and validation cohorts, respectively. Age, admission heart rate, left atrial diameter, right atrial diameter, heart failure, brain natriuretic peptide (BNP) level, less statin use, and no percutaneous coronary intervention (PCI) were independent predictors of NOAF. The AUC was 0.891 (95% CI: 0.863-0.920) and 0.839 (95% CI: 0.796-0.883) for the training and validation cohort, respectively, and the model passed the calibration test (P > 0.05). The clinical utility evaluation shows that the model has a clinical net benefit within a certain range of the threshold probability.

CONCLUSION

A model with strong predictive power was constructed for predicting the risk of NOAF in patients with ACS during hospitalization. It might help with the identification of ACS patients at risk and early intervention of NOAF during hospitalization.

Impact of de novo tachyarrhythmias in patients with prior acute coronary syndrome

Although the incidence of acute coronary syndrome (ACS) has increased over the decades, the overall prognosis has improved with newer stents, tailored medication, and better intervention techniques. Atrial fibrillation (AF) and ventricular arrhythmia at the time of ACS diagnosis are known indicators of a poor acute prognosis. However, there is a lack of data regarding the long-term arrhythmic impact of ventricular tachyarrhythmia (VA) on mortality in ACS patients. This study sought to elucidate the impact of tachyarrhythmia on mortality during long-term follow-up in patients with a history of ACS. This retrospective study was conducted in a single university hospital, and it evaluated the clinical outcomes, especially regarding cardiovascular mortality and readmission. The enrolled patients underwent percutaneous coronary intervention (PCI) for ACS between February 2004 and March 2018. Clinical information was attained by a thorough chart review. We retrospectively analyzed 560 ACS patients. We reviewed all electrocardiograms (ECGs) before and immediately after PCI, during hospitalization, and within 3 months of the index PCI. Three months after the index PCI procedure, any Holter monitoring or ECG was also reviewed for arrhythmia diagnosis. During follow-up, 91 patients were diagnosed with AF and 36 patients were diagnosed with VA. Overall mortality was related to the presence of anemia, low body mass index, low left ventricular ejection fraction after PCI, late-diagnosed AF, and any VA during follow-up. Readmission was higher in patients with chronic kidney disease and newly diagnosed AF during the follow-up. Diagnosis of late tachyarrhythmia during follow-up was associated with increased mortality in post-ACS patients.

Comparative Safety and Effectiveness of Ticagrelor versus Clopidogrel in Patients With Acute Coronary Syndrome: An On-Treatment Analysis From a Multicenter Registry

Background:

The net clinical benefit of ticagrelor over clopidogrel in acute coronary syndrome (ACS) has recently been questioned by observational studies which did not account for time-dependent confounders. We aimed to assess the comparative safety and effectiveness of ticagrelor vs. clopidogrel accounting for non-adherence in a real-life setting.

Methods

This is a prospective, multicenter cohort study of patients with ACS discharged on ticagrelor or clopidogrel between 2015 and 2019. Major exclusions were previous intracranial bleeding, and the use of prasugrel or oral anticoagulation. Association of P2Y₁₂ inhibitor therapy with 1-year risk of Bleeding Academic Research Consortium Type 3 or 5 bleeding; major adverse cardiac events (MACEs), a composite endpoint of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, or urgent target lesion revascularization; definite/probable stent thrombosis; vascular death; and net adverse clinical event (a composite endpoint of major bleeding and MACE) were analyzed according to the “on-treatment” principle, using fully adjusted Cox and Fine-Gray regression models with doubly robust inverse probability of censoring weighted estimators.

Results

Among 2,070 patients (mean age 63 years, 27% women, 62.5% ST-elevation MI), 1,035 were discharged on ticagrelor and clopidogrel, respectively. Ticagrelor-treated patients were younger and had few comorbidities, but high rates of medication non-compliance, compared with clopidogrel users. After comprehensive multivariate adjustments, ticagrelor did not increase the risk of major bleeding compared with clopidogrel [subhazard ratio, 1.40; 95% confidence interval (CI), 0.96–2.05], while proved superior in reducing MACE (hazard ratio 0.62; 95% CI, 0.43–0.90), vascular death (subhazard ratio, 0.71; 95% CI, 0.52–0.97) and definite/probable stent thrombosis (subhazard ratio, 0.54; 95% CI, 0.30-0.79); thereby resulting in a favorable net clinical benefit (hazard ratio 0.78; 95% CI, 0.60–0.98) compared with clopidogrel. Results from sensitivity analyses were consistent with those from the primary analysis, whereas those from the intention-to-treat (ITT) analysis went in the opposite direction.

Conclusion

Among all-comers with ACS, ticagrelor did not significantly increase the risk of major bleeding, while resulting in a net clinical benefit compared with clopidogrel. Further research is warranted to confirm these findings in high bleeding risk populations.

CREA-ARIAM Andalucía

(ClinicalTrials.gov Identifier: NCT02500290); Current pre-specified analysis (ClinicalTrials.gov Identifier: NCT04630288).

De novo and pre-existing atrial fibrillation in acute coronary syndromes: impact on prognosis and cardiovascular events in long-term follow-up

AIMS

The aim of the study was to compare in-hospital and long-term prognosis in patients with acute coronary syndromes (ACS) and de novo vs. pre-existing atrial fibrillation (AF). Atrial fibrillation increases the risk of serious adverse events including death in patients with ACS. However, it is unclear whether de novo and pre-existing AF portend a different risk.

METHODS AND RESULTS

We analysed the incidence, clinical characteristics, and in-hospital and long-term outcomes in patients with AF and ACS based on combined data from Polish Registry of Acute Coronary Syndrome (PL-ACS) (n = 581 843) and SILICARD (n = 852 063) databases. Atrial fibrillation at admission was diagnosed in of 6.16% patients [de novo: 1129 (2.46%); pre-existing: 1691 (3.7%)]. Groups were compared (N = 1023 vs. 1023) after matching for relevant clinical factors. De novo and pre-existing AF differed in in-hospital diuretic (52% vs. 58%; P = 0.008) and aldosterone inhibitor (27.5% vs. 32.5%; P = 0.02) use, Thrombolysis In Myocardial Infarction (TIMI) flow before percutaneous coronary intervention (P = 0.016), and diuretic (52.1% vs. 58%; P = 0.008) and oral anticoagulant (27.5% vs. 32.5%; P = 0.018) use at discharge. In-hospital mortality in the de novo AF group was significantly higher (13.1% vs. 8.31%; P = 0.0005). Post-discharge 12-month survival was similar between groups (14.5% vs. 15.3%, P = 0.63). Long-term re-hospitalization due to heart failure (22.7% vs. 17.2%; P < 0.005) and medical contact due to AF (48.4% vs. 26.1%, P < 0.0001) rates were higher in the group with pre-existing AF, without the difference of stroke or myocardial infarction occurrence.

CONCLUSION

De novo AF accounts for 40% of all AF cases in ACS patients and is an unfavourable in-hospital prognostic factor. The occurrence of de novo AF during ACS should require special attention and caution in the treatment of these patients.

Feasibility and preliminary efficacy of acupuncture for angina in an underserved diverse population

PURPOSE

Stable angina is ischemic chest pain on exertion or with emotional stress. Despite guideline-directed therapy, up to 30% of patients have suboptimal pain relief. The aims of this study were to: (1) determine the feasibility and acceptability of a randomized controlled trial (RCT) of acupuncture; and (2) evaluate preliminary efficacy of acupuncture with respect to reduction of pain and increased functional status and health-related quality of life (HRQoL).

METHODS

Participants with stable angina for ⩾1 month received either a standardized acupuncture protocol, twice per week for 5 weeks, or an attention control protocol. Measures included the McGill Pain Questionnaire (average pain intensity (API), pain now) and the Seattle Angina Questionnaire-7 (functional status, symptoms, and HRQoL). Feasibility was defined as ⩾80% recruitment, ⩾75% retention following enrollment, and ⩾80% completion. Descriptive statistics and mixed-effects linear regression were used for analysis.

RESULTS

The sample (n = 24) had a mean age of 59 ± 12 years, was predominantly female (63%), and represented minority groups (8% White, 52% Black, 33% Hispanic, and 8% Other). Feasibility was supported by 79% retention and 89% completion rates. The recruitment rate (68%) was slightly lower than expected. Acceptability scores were 87.9% for the acupuncture group and 51.7% for the control group. Outcomes were significantly better for the acupuncture versus control groups (API, b = -2.1 (1.1), p = 0.047; functional status, b = 27.6 (7.2), p < 0.001; and HRQoL, b = 38.8 (11.9), p = 0.001).

CONCLUSIONS AND IMPLICATIONS

Acupuncture was feasible and acceptable in our diverse sample. We were slightly under the recruitment target of 80%, but participants who started the study had a high likelihood of completing it. Acupuncture shows promise for stable angina, but its effectiveness needs to be confirmed by a larger, adequately powered RCT.

TRIAL REGISTRATION NUMBER

NCT02914834 (ClinicalTrials.gov).

The association between atrial fibrillation and in-hospital outcomes in chronic kidney disease patients with acute coronary syndrome: findings from the improving care for cardiovascular disease in China-acute coronary syndrome (CCC-ACS) project

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia in patients with chronic kidney disease (CKD) and acute coronary syndrome (ACS). This study aimed to explore the frequency and impact of AF on clinical outcomes in CKD patients with ACS.

Methods

CKD inpatients with ACS between November 2014 and December 2018 were included based on the improving care for cardiovascular disease in China-ACS (CCC-ACS) project. Included patients were divided into an AF group and a non-AF group according to the discharge diagnosis. Multivariable logistic regression was used to adjust for potential confounders.

Results

A total of 16,533 CKD patients with ACS were included. A total of 1418 (8.6%) patients had clinically recognized AF during hospitalization, 654 of whom had an eGFR of 45 to < 60 ml/min/1.73 m², and 764 had an estimated glomerular filtration rate (eGFR) < 45 ml/min/1.73 m². Compared with the non-AF group, the AF group had a higher risk of in-hospital mortality [OR 1.250; 95% CI (1.001–1.560), P = 0.049] and major adverse cardiovascular events (MACEs) [OR 1.361; 95% CI (1.197–1.547), P < 0.001]. We also found that compared with patients with eGFR 45 to < 60 ml/min/1.73 m², patients with eGFR < 45 ml/min/1.73 m² had a 1.512-fold increased risk of mortality and a 1.435-fold increased risk of MACEs.

Conclusions

AF was a risk factor affecting the short-term prognosis of ACS patients in the CKD population. Furthermore, the lower the eGFR, the higher the risk of in-hospital mortality and MACEs in CKD patients with ACS.

Trial registry: Clinicaltrial.gov, NCT02306616. Registered 29 November 2014, https://clinicaltrials.gov/ct2/show/NCT02306616?term=NCT02306616&draw=2&rank=1

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02125-z.

The Effect of Atrial Fibrillation on the Long-Term Mortality of Patients with Acute Coronary Syndrome: The TACOS Study

INTRODUCTION

Atrial fibrillation (AF) is a frequent finding in acute coronary syndrome (ACS), but there is conflicting scientific evidence regarding its long-term impact on patient outcome. The aim of this study was to survey and compare the ≥10-year mortality of ACS patients with sinus rhythm (SR) and AF.

METHODS

Patients were divided into 2 groups based on rhythm in their 12-lead ECGs: (1) SR (n = 788) at hospital admission and discharge (including sinus bradycardia, physiological sinus arrhythmia, and sinus tachycardia) and (2) AF/atrial flutter (n = 245) at both hospital admission and discharge, or SR and AF combination. Patients who failed to match the inclusion criteria were excluded from the final analysis. The main outcome surveyed was long-term all-cause mortality between AF and SR groups during the whole follow-up time.

RESULTS

Consecutive ACS patients (n = 1,188, median age 73 years, male/female 58/42%) were included and followed up for ≥10 years. AF patients were older (median age 77 vs. 71 years, p < 0.001) and more often female than SR patients. AF patients more often presented with non-ST-elevation myocardial infarction (69.8 vs. 50.4%, p < 0.001), had a higher rate of diabetes (31.0 vs. 22.8%, p = 0.009), and were more often using warfarin (32.2 vs. 5.1%, p < 0.001) or diuretic medication (55.1 vs. 25.8%, p < 0.001) on admission than patients with SR. The use of warfarin at discharge was also more frequent in the AF group (55.5 vs. 14.8%, p < 0.001). The rates of all-cause and cardiovascular mortality were higher in the AF group (80.9 vs. 50.3%, p < 0.001, and 73.8 vs. 69.6%, p = 0.285, respectively). In multivariable analysis, AF was independently associated with higher mortality when compared to SR (adjusted HR 1.662; 95% CI: 1.387-1.992, p < 0.001).

CONCLUSION

AF/atrial flutter at admission and/or discharge independently predicted poorer long-term outcome in ACS patients, with 66% higher mortality within the ≥10-year follow-up time when compared to patients with SR.

The role of CHA2DS2-VASc score in evaluating patients with atrial fibrillation undergoing percutaneous coronary intervention

OBJECTIVE

The aim of the review was to assess whether CHA2DS2-VASc score is predictive of mortality in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI).

BACKGROUND

The CHA2DS2-VASc score is validated in predicting stroke risk in atrial fibrillation. The optimum management strategy for these patients undergoing PCI is still debated.

METHODS

The CHA2DS2-VASc score was calculated in consecutive patients with atrial fibrillation undergoing PCI in a large Australian registry between 2007 and 2013. Patients were divided into low (1-2), intermediate (3-4) and high (≥5) groups. Clinical and procedural data, 30-day, 1-year and long-term outcomes were compared between the groups.

RESULTS

A total of 564 patients were included in our analysis. Patients with high CHA2DS2-VASc scores had higher mortality rates at 1-year (2, 8, 15; P = 0.002) and long-term (6, 20, 37; P < 0.001). High-risk patients were more likely to have renal impairment and multivessel disease. Increasing CHA2DS2-VASc score was associated with increased risk of stroke (0, 2, 6; P = 0.03). However, only 41.9% received anticoagulation, with no difference across the risk groups. When compared to low-risk, intermediate [HR 3.57; 95% confidence interval (CI), 1.28-9.92; P = 0.015] and high (hazard ratio 7.82; 95% CI, 2.88-21.24; P < 0.001) CHA2DS2-VASc scores were significant predictors of long-term mortality.

CONCLUSIONS

Higher CHA2DS2-VASc scores in patients with atrial fibrillation undergoing PCI are associated with significantly worse outcomes. Despite being high-risk, the patients in this cohort are likely undertreated with anticoagulation. Close clinical follow-up with greater utilization of anticoagulation and optimal medical therapy has the potential to improve long-term outcomes.

Coronary Flow Disturbance Phenomenon After Percutaneous Coronary Intervention Is Associated with New-Onset Atrial Fibrillation in Patients with Acute Myocardial Infarction

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI). Although previous studies have investigated mortality rates and the incidences of adverse events associated with new-onset AF (NOAF) in patients with AMI, the effects of emergency percutaneous coronary intervention (PCI) on the incidence of NOAF in patients with AMI remain unclear. The purpose of this study was to investigate the relationship of clinical characteristics, medical history, and the coronary flow disturbance phenomenon (TIMI < 3) following emergency PCI with NOAF in patients with AMI. Between 2012 and 2016, 731 patients with AMI underwent PCI at our facility. Among these, 52 had a history of chronic/paroxysmal AF before admission and were excluded. The remaining 679 patients (mean age 66.4 years, 532 males) were analyzed in this retrospective observational study.New-onset AF was observed in 45 patients (6.6%). In univariate analysis, the hazard ratios (HRs) for patient age (HR 1.04, 95%CI 1.02-1.07), Killip II-IV (HR 2.34, 95%CI 1.29-4.23), elevated D-dimer level (> 1.0 μg/mL; HR 3.32; 95%CI 1.77-6.23), and coronary flow disturbance phenomenon (HR 5.61; 95%CI 2.88-10.9) were significantly higher in the NOAF group. In multivariate analysis, an elevated D-dimer level (> 1.0 μg/mL; HR 2.44; 95%CI 1.17-5.11) and coronary flow disturbance phenomenon (HR 4.61; 95%CI 2.29-9.27) were found to be independent risk factors for NOAF. An elevated D-dimer level at admission and the presence of coronary flow disturbance phenomenon after PCI were risk factors for NOAF following emergency PCI in patients with AMI.

Fondaparinux versus enoxaparin in the contemporary management of non-ST-elevation acute coronary syndromes. Insights from a multicenter registry

BACKGROUND

Fondaparinux is thought to have the most favorable risk-benefit profile among all anticoagulants in non-ST-elevation acute coronary syndrome (NSTE-ACS). However, conflicting findings exist whether this holds true in current clinical practice. We aimed to assess the net clinical benefit of fondaparinux versus enoxaparin in the contemporary management of NSTE-ACS.

METHODS

Analysis of prospective multicenter registry data of NSTE-ACS patients who received fondaparinux or enoxaparin from February 2015, through December 2017. Survival models within a competing risks framework including site-specific random effects, were used to assess the composite of clinically relevant bleedings and major adverse cardiovascular events at 30 days.

RESULTS

Of 2094 patients, 1724 (82%) received enoxaparin and 370 (18%) fondaparinux. Both groups were comparable except for a lower prevalence of diabetes and renal impairment, and greater use of transradial approach in the fondaparinux group. Multivariate analysis revealed a net clinical benefit in favour of fondaparinux versus enoxaparin (Subhazard Ratio [SHR] 0.59; 95%CI 0.37-0.92), mainly driven by a reduction in bleeding (SHR 0.57; 95%CI 0.37-0.89). Exploratory analysis suggested greater reductions in bleeding with fondaparinux among patients undergoing transradial approach, revealing a significant interaction between treatment and vascular access on the multiplicative scale (P_interaction = 0.0056), but not on an additive scale (P = 0.457). Propensity-score-matching analysis yielded similar results.

CONCLUSIONS

In contemporary management of NSTE-ACS, fondaparinux seems to provide a favorable net clinical benefit compared with enoxaparin, primarily driven by a bleeding reduction. Effect modification on the safety profile of fondaparinux by the vascular access approach warrants further investigation.

Effects of Atrial Fibrillation and Chronic Kidney Disease on Major Adverse Cardiovascular Events

Atrial fibrillation (AF) is strongly linked to chronic kidney disease (CKD) and both of these conditions contribute to poor cardiovascular outcomes. We evaluated the impact of renal failure on major adverse cardiovascular events (MACE) in AF, and predictive value of the 2MACE score in this post-hoc analysis of the AMADEUS trial. The primary endpoint was MACE (composite of myocardial infarction, cardiac revascularisation and cardiovascular mortality). Secondary endpoints included the composite of stroke, major bleeding and non-cardiovascular mortality, and each of the specific outcomes separately. Of the 4,554 patients, 1,526 (33.5%) were females and the median age was 71 (IQR 64 to 77) years. There were 3,838 (84.3%) non-CKD and 716 (15.7%) CKD patients. The incidence of cardiovascular and non-cardiovascular mortality were 1.41% and 2.44% per 100 patient-years, respectively. There was no significant difference in crude study endpoints between the groups. Multivariable regression analysis found no association between CKD and MACE (HR 1.03 [95% CI, 0.45 to 2.34]). The c-index of the 2MACE score for MACE was 0.65 (95% CI, 0.59 to 0.71, p <0.001). In the presence of CKD, each additional point of the 2MACE score contributed to a greater risk of MACE (HR 3.17 [95% CI, 1.28 to 7.85] vs 1.48 [95% CI, 1.17 to 1.87] in the non-CKD group). In conclusion, the 2MACE score may be a useful tool for clinical risk stratification of high-risk AF patients with CKD and those at high MACE risk could be targeted for more intensive cardiovascular prevention strategies. The presence of CKD was not found to be independently associated with MACE in AF patients.

Prevalence and clinical significance of totally occluded infarct-related arteries in patients with non-ST-segment elevation acute coronary syndromes

Background Seemingly conflicting findings exist regarding the prognostic impact of totally occluded infarct-related arteries (oIRA) in non-ST elevation acute coronary syndromes (NSTE-ACS). Methods Retrospective analysis of prospective multicenter registry data comprising a single-center NSTE-ACS cohort, aimed at assessing the impact of occluded (TIMI flow 0/1) versus patent culprit vessels (pIRA, TIMI flow 2/3) on the composite endpoint of all-cause death and cardiogenic shock events at 30 days. Results Of 568 patients, 183 (32.5%) had oIRA. Male sex, refractory angina, ECG suggestive of multivessel or left main disease, and larger infarct sizes with inferior/posterolateral wall involvement, were identified as highly specific markers of oIRA. Successful culprit-lesion revascularization occurred more frequently in patent than in oIRA (90% vs. 96%; P = 0.013). Conversely, patients with oIRA more frequently achieved successful revascularization of concurrent non-IRAs including chronic total occlusions than did those with pIRA (28% vs. 3%; P = 0.0005). Multivariate analysis revealed neutral effects of oIRA on outcomes and identified incomplete revascularization as a powerful predictor of mortality. Moderation analysis revealed a significant interaction between completeness of revascularization and IRA patency, whereby among the incompletely revascularized patients, those with oIRA enjoyed a significant survival advantage over their counterparts with pIRA (11.8% vs. 28%, adjusted OR 0.34; 95% CI 0.10-0.73; P_interaction = 0.012). Conclusions Approximately one third of NSTE-ACS patients in this cohort had oIRA. However, compared with pIRA, the occurrence of oIRA did not portend poor outcomes, likely resulting from the higher rate of incomplete revascularization and increased risk of subsequent mortality in patients with pIRA. These exploratory findings warrant further investigation.

Outcomes of Percutaneous Coronary Intervention in Atrial Fibrillation Patients Presenting With Acute Myocardial Infarction: Analysis of Nationwide Inpatient Sample Database

BACKGROUND

Atrial fibrillation (AF) is common in patients presenting with myocardial infarction (MI). Percutaneous coronary intervention (PCI) has been shown to improve cardiovascular outcomes in MI. However, outcomes of PCI in AF patients presenting with MI remains largely unknown.

METHODS

We analyzed the Nationwide Inpatient Sample (NIS) database to calculate the age adjusted mortality rate for PCI in AF patients presenting with MI between 2002 and 2011, in adults over 40 years of age. This was then compared to the mortality rate for PCI in non-AF patients with MI. Specific ICD-9-CM codes were used to identify patients and outcomes.

RESULTS

Of 3,226,405 PCIs done during the study period, 472,609 (14.6%) PCIs were done on AF patients of which 137,870 PCIs were for MI. About 60% of these patients were male. Patients with AF were older (71.3 ± 10.6 years). Overall the number of PCIs shows a declining trend from 2002 to 2011, but for MI patients the number of PCIs appears stable over the years. The age adjusted in-hospital mortality following PCI in MI was significantly higher in AF group compared to the non-AF group (190.24 ± 17.21vs 109.08 ± 5.89 per 100,000; P < 0.01). This trend was seen during the entire study period.

CONCLUSIONS

AF is prevalent in MI patients undergoing PCI. AF is associated with increased mortality following PCI for acute MI. AF is not a benign arrhythmia in MI patients and close attention is warranted in these patients to improve mortality.

Effect of Concomitant Atrial Fibrillation on In-Hospital Outcomes of Non-ST-Elevation-Acute Coronary Syndrome-Related Hospitalizations in the United States

Atrial fibrillation (AF) is the most common arrhythmia in patients presenting with acute coronary syndrome (ACS). The present study examined the rates and trends of clinical outcomes and management strategies of non-ST-elevation ACS (NSTE-ACS) related hospitalizations in the United States, in patients with concomitant AF compared with those in sinus rhythm (SR). We analyzed the "Nationwide Inpatient Sample" database (2004 to 2014) for patients with a primary discharge diagnosis of NSTE-ACS, and further stratified the cohort on the basis of diagnoses into SR and AF groups. Multivariate analysis was performed to examine the association between AF and major adverse cardiovascular and cerebrovascular events (composite of mortality, stroke, and cardiac complications) and its components. Of 4,668,737 NSTE-ACS hospitalizations, the proportions of SR and AF groups were 82.4% (3,848,202) and 17.6% (820,535), respectively. The incidence of AF increased significantly over time from 16.5% (2004) to 19.3% (2014). The AF group was at a greater risk of adverse outcomes with higher rates and adjusted relative risk (RR) of major adverse cardiovascular and cerebrovascular events (12.9% vs 5.3%; RR 1.74 [1.72, 1.75]), mortality (6.5% vs 3.3%; RR 1.12 [1.11, 1.13]), stroke (2.7% vs 1.5%; RR 1.32 [1.30, 1.34]), and bleeding (14.7% vs 8.8%; RR 1.42 [1.41, 1.43]). Furthermore, the AF group was less likely to receive coronary angiography (47.1% vs 58%) and percutaneous coronary intervention (18.7% vs 32.6%) in comparison to SR (p <0.001 for all outcomes). In conclusion, patients with concomitant AF and NSTE-ACS are less likely to be offered an invasive management strategy for their ACS and are associated with worse complications and higher mortality.

Adverse Outcomes Associated with Pre-Existing and New-Onset Atrial Fibrillation in Patients with Acute Coronary Syndrome: A Retrospective Cohort Study

Introduction

Atrial fibrillation (AF) often occurs in patients with acute coronary syndrome (ACS). It remains unclear whether pre-existing or new-onset AF confers different risk in patients with ACS.

Methods

We conducted a retrospective cohort study using Taiwan’s National Health Insurance Research Database. Patients who were hospitalized with a primary diagnosis of ACS from 2005 to 2009 were studied. Major outcomes were mortality, heart failure, and combined ischemic stroke/systemic embolism (IS/SE). The date of the first ACS diagnosis was defined as the index date. Pre-existing AF was defined as AF occurring before the index date. New-onset AF was defined as AF that started after or at the same time as the ACS diagnosis.

Results

Among 6663 patients with ACS, 488 (7.3%) had pre-existing AF and 479 (7.2%) had new-onset AF. Compared to patients with pre-existing AF, those with new-onset AF were younger, less likely to have co-morbidities, and more likely to receive evidence-based therapy. The un-adjusted risks of adverse outcomes in both groups were similar. Compared to pre-existing AF, new-onset AF was significantly associated with a higher adjusted risk of death (hazard ratio 1.27, 95% confidence interval 1.06–1.52) and IS/SE (hazard ratio 1.49, 95% confidence interval 1.01–2.20). The significant associations between new-onset AF and adverse outcomes were more likely to be observed in elderly patients with ACS.

Conclusions

New-onset AF during ACS was associated with a significantly increased risk of adverse outcomes, especially in the elderly patients.

The quality of warfarin therapy and CHA2DS2-VASc score associate with the incidence of myocardial infarction and cardiovascular outcome in patients with atrial fibrillation: data from the nationwide FinWAF Registry

Aims

The impact of the quality of warfarin therapy on cardiovascular outcomes excluding stroke is largely unknown. The aims of this study were to evaluate the association between the warfarin control and the incidence and outcome of myocardial infarction (MI) and to validate the predictive value of the CHA2DS2-VASc score for MI in atrial fibrillation (AF) patients taking warfarin.

Methods and results

The nationwide FinWAF Registry consists of 54 568 AF patients (mean age 73.31 ± 10.7 years, 52% men) taking warfarin. The quality of warfarin therapy was assessed continuously by calculating the time in therapeutic range within a 60-day window using the Rosendaal method (TTR60). Adjusted Cox proportional hazards models were prepared for the incidence of MI and cardiovascular mortality in six different TTR60 categories. During the 3.2 ± 1.6 years of follow-up, the annual incidence of MI (95% confidence interval) was 3.3% (3.0-3.5%), 2.9% (2.6-3.3%), 2.4% (2.1-2.7%), 1.9% (1.7-2.2%), 1.7% (1.5-2.0%), and 1.2% (1.1-1.3%) among patients with TTR60 <40%, 40-50%, 50-60%, 60-70%, 70-80%, and >80%, respectively. Well-managed warfarin therapy (TTR60 > 80%) was associated also with a lower cardiovascular mortality, whereas a high CHA2DS2-VASc score correlated with poor outcome.

Conclusion

Cardiovascular outcome was superior among AF patients with good warfarin control and in those with a low CHA2DS2-VASc score. The inverse association between the TTR60 and incidence of MI and cardiovascular mortality indicate that in AF patients the quality of warfarin therapy is critical not only for prevention of stroke but also with regard to cardiovascular outcome.

Influence of Atrial Fibrillation on Outcomes in Patients Who Underwent Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Atrial fibrillation (AF) is a common co-morbidity among patients presenting with acute ST-segment elevation myocardial infarction (STEMI). Previously, small studies have reported an association between AF and poorer outcomes among patients with STEMI. We performed this study to investigate the impact of AF on in-hospital outcomes in patients with STEMI treated with primary percutaneous coronary intervention (PPCI) using a large national database. The study population constituted of patients 18 years and older with a primary discharge diagnosis of STEMI and who underwent PPCI. Using a 2:1 matching protocol, matched groups of patients with AF (N = 24,680) and without (N = 49,198) were developed. Among 1,493,859 patients with STEMI who underwent PPCI, 129,354 patients (8.7%) had AF. In the propensity-matched cohort, adjusted in-hospital mortality was significantly higher for patients with AF compared with patients with no AF (10.3% vs 9.4%) (adjusted odds ratio [OR] 1.10; confidence interval [CI] 1.06 to 1.16; p <0.0001). Patients with AF were also at higher risk of heart failure, cardiogenic shock, acute stroke, acute kidney injury, vascular complications, need for blood transfusion, and a composite outcome of gastrointestinal and retroperitoneal bleeding. Patients with AF were less likely to be treated with drug-eluting stent compared with patients without AF (51.4% vs 56.6%) (adjusted OR 0.81; CI 0.79 to 0.84; p <0.001). Among patients presenting with STEMI and who underwent PPCI, AF is present in about 8% of patients. In a propensity-matched analysis using a large national database, AF was found to be independently associated with a higher risk of in-hospital mortality and of other complications in these patients.

Non-vitamin K Antagonist Oral Anticoagulant After Acute Coronary Syndrome: Is There a Role?

Despite dual antiplatelet therapy (DAPT) including potent P2Y12 inhibitors, recurrent ischaemic events occur in a significant number of patients after acute coronary syndrome (ACS), warranting new antithrombotic strategies. Combinations of non-vitamin K antagonist oral anticoagulant (NOAC) with antiplatelet therapy have been tested in several large phases II and III randomised trials. Overall, current evidence suggests that the use of NOACs on top of DAPT after ACS reduces the rate of recurrent ischaemic events, albeit at the price of increased risk for major bleeding. In the particular field of patients with ACS and atrial fibrillation, NOACs may be associated with reduced bleeding complications compared with vitamin K antagonist. Further randomised trials evaluating low-dose NOAC combined with single antiplatelet therapy are warranted.

Current Use of Oral Anticoagulants and Prognostic Analysis in Patients with Atrial Fibrillation Undergoing Coronary Stenting

Background:

It is currently believed that triple oral antithrombotic therapy in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI) should be recommended if there are no contraindications. However, selecting triple therapy for AF patients undergoing PCI is still challenging when bleeding risk is considered. This study aimed to investigate the current use of oral anticoagulants (Vitamin K antagonists [VKA]) and perform prognostic analysis in real-world patients with AF undergoing coronary stenting.

Methods:

A total of 276 consecutive coronary artery disease (CAD) patients with or without AF undergoing coronary stenting were retrospectively evaluated and analyzed. The univariate and multivariate analyses were conducted to explore the current use of VKA and prognosis of patients with AF undergoing coronary stenting. The primary end-point was composite of all-cause death, nonfatal recurrent myocardial infarction, stroke, serious bleeding events, unplanned repeat revascularization, and worsening heart failure at 12-month follow-up after coronary stenting.

Results:

AF patients undergoing coronary stenting have more clinical concomitant diseases. Only 9.0% AF patients after coronary stenting received triple antithrombotic therapy (VKA, aspirin, and clopidogrel) at discharge. AF was independently associated with increased risk of the 12-month composite end-points (relative risk = 5.732, 95% confidence interval 1.786–18.396, P = 0.003).

Conclusions:

In real-life AF patients undergoing coronary stenting, guideline-recommended VKA was less used. AF patients had adjusted worse prognosis during 12-month follow-up after discharge. It is of utmost importance to improve the current status of oral anticoagulants use.

Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome. Results of a "Real World" Multicenter Registry

INTRODUCTION AND OBJECTIVES

The incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the "real world" remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS).

METHODS

A multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models.

RESULTS

The study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094).

CONCLUSIONS

In a "real world" setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel.

Antiplatelet and Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Coronary Stenting

Stroke prevention is the main priority in the management cascade of atrial fibrillation. Most patients require long-term oral anticoagulation (OAC) and may require percutaneous coronary intervention. Prevention of recurrent cardiac ischemia and stent thrombosis necessitate dual antiplatelet therapy (DAPT) for up to 12 months. Triple antithrombotic therapy with OAC plus DAPT of shortest feasible duration is warranted, followed by dual antithrombotic therapy of OAC and antiplatelet agent, and OAC alone after 12 months. Because of elevated risk of hemorrhagic complications, new-generation drug-eluting stents, lower-intensity OAC, radial access, and routine use of gastric protection with proton pump inhibitors are recommended.

High-sensitivity troponin and novel biomarkers for the early diagnosis of non-ST-segment elevation myocardial infarction in patients with atrial fibrillation

AIMS

To evaluate the diagnostic performance of high-sensitivity troponin I (hsTnI) and other novel biomarkers for diagnosing non-ST-segment elevation myocardial infarction (NSTEMI) in patients with atrial fibrillation.

METHODS

In an acute chest pain cohort (N=1673), mean age 61.4±13.6 (34% female), we measured hsTnI and 13 established and novel biomarkers reflecting ischaemia, necrosis, inflammation, myocardial stress, angiogenesis on admission and after three hours in order to investigate their diagnostic accuracy for NSTEMI.

RESULTS

In atrial fibrillation patients (N=299) hsTnI on admission had the best discriminatory ability for NSTEMI (area under the curve 0.97) with only two novel biomarkers, copeptin and heart-type fatty acid binding protein, having area under the curve >0.70. Measured biomarkers showed comparable discriminatory ability in atrial fibrillation and non-atrial fibrillation patients. The combination of hsTnI on admission with additional biomarkers did not clinically significantly improve diagnostic performance. In atrial fibrillation patients, hsTnI concentrations ⩽21.7 ng/L (99th percentile in a healthy German cohort) on admission gave a negative predictive value of ~100% (95% confidence interval 97-100%). The combination of hsTnI on admission and absolute change of hsTnI concentration after three hours of ⩾40 ng/L resulted in a positive predictive value of 81.2% and sensitivity of 88.6%. Diagnostic accuracy was validated in an independent cohort (N=1076).

CONCLUSION

The diagnostic accuracy of hsTnI in patients with acute chest pain and atrial fibrillation is high and comparable to those without atrial fibrillation. Absolute change in hsTnI concentration enhanced diagnostic performance. No clinically relevant improvement was achieved by adding other biomarkers.

Non-vitamin K oral anticoagulant treatment in elderly patients with atrial fibrillation and coronary heart disease

Atrial fibrillation (AF) is the most frequent sustained arrhythmia. Overall prevalence is estimated to 5.5% and the incidence increases with age. As the population ages, the prevalence and costs of AF are expected to increase. AF is the most important cause of stroke in patients >75years. Until recently, Vitamin K antagonists (VKAs) were the only available oral anticoagulants (OACs) evaluated for long-term treatment of patients with AF with or without coronary heart disease (CHD). This situation was challenged by introduction of non-VKA oral anticoagulants (NOACs). In AF, use of NOACs seems to be as effective and safe as VKAs, especially in elderly patients. AF and CHD are frequently associated and the question of antithrombotic management in aging patients is delicate. In elderly patients experiencing a new AF episode after an acute coronary syndrome, triple antithrombotic therapy should be as short as possible in order to decrease the risk of major bleedings. To date, there is no specific study or available guidelines regarding the NOACs use specifically in elderly patients experiencing both AF and CHD. In this review, we try to provide a perspective on NOACs future incorporation into clinical practice in elderly patients with both AF and CHD.

A Review of the Relationship of Atrial Fibrillation and Acute Coronary Syndrome

Atrial fibrillation (AF) is the most common arrhythmia encountered by clinicians. Clinical decision-making focuses on reducing ischemic stroke risk in AF patients; however, AF is also associated with an increased risk of acute coronary syndromes (ACS). Patients with ACS and concurrent AF are less likely to receive appropriate therapies and more likely to experience adverse outcomes than ACS patients in sinus rhythm (SR). Clinicians may be able to stratify ACS patients at increased risk of AF development based on clinical characteristics. Evidence supporting specific therapeutic options for prevention of ACS in AF patients or for prevention of AF in ACS patients is limited, however there is some evidence of differing effects among oral anticoagulant regimens in these populations. Investigations of the relationship of AF with the full spectrum of ACS are not well described and should be the focus of future research.

Oral anticoagulants in coronary heart disease (Section IV). Position paper of the ESC Working Group on Thrombosis - Task Force on Anticoagulants in Heart Disease

Until recently, vitamin K antagonists (VKAs) were the only available oral anticoagulants evaluated for long-term treatment of patients with coronary heart disease (CHD), particularly after an acute coronary syndrome (ACS). Despite efficacy in this setting, VKAs are rarely used because they are cumbersome to administer. Instead, the more readily manageable antiplatelet agents are the mainstay of prevention in ACS patients. This situation has the potential to change with the introduction of non-VKA oral anticoagulants (NOACs), which are easier to administer than VKAs because they can be given in fixed doses without routine coagulation monitoring. The NOACs include dabigatran, which inhibits thrombin, and apixaban, rivaroxaban and edoxaban, which inhibit factor Xa. Apixaban and rivaroxaban were evaluated in phase III trials for prevention of recurrent ischaemia in ACS patients, most of whom were also receiving dual antiplatelet therapy with aspirin and clopidogrel. Although at the doses tested rivaroxaban was effective and apixaban was not, both agents increased major bleeding. The role for the NOACs in ACS management, although promising, is therefore complicated, because it is uncertain how they compare with newer antiplatelet agents, such as prasugrel, ticagrelor or vorapaxar, and because their safety in combination with these other drugs is unknown. Ongoing studies are also now evaluating the use of NOACs in non-valvular atrial fibrillation patients, where their role is established, with coexistent ACS or coronary stenting. Focusing on CHD, we review the results of clinical trials with the NOACs and provide a perspective on their future incorporation into clinical practice.

Prognostic impact of clopidogrel pretreatment in patients with acute coronary syndrome managed invasively

Pretreatment with antiP2Y12 agents before angiography in acute coronary syndrome (ACS) is associated with a reduction in thrombotic events. However, recent evidences have questioned the benefits of upstream antiP2Y12, reporting a higher incidence of bleeding. We analyzed the prognostic impact of clopidogrel pretreatment in a large cohort of invasively managed patients with ACS. In hospital, safety and efficacy of clopidogrel pretreatment were retrospectively analyzed in patients included in the ARIAM-Andalucía Registry (Analysis of Delay in Acute Myocardial Infarction). Propensity score and inverse probability of treatment weighting analysis were performed to control treatment selection bias. Results were stratified by ACS type. Sensitivity analyses were used to explore stability of the overall treatment effect. Of 9,621 patients managed invasively, 69% received clopidogrel before coronary angiography. In the ST-elevation myocardial infarction group, pretreatment was associated with a significant reduction in reinfarction (odds ratio 0.53, 95% confidence interval [CI] 0.27 to 0.96; p = 0.027), stent thrombosis (odds ratio 0.15, 95% CI 0.06 to 0.38; p <0.0001), and mortality (odds ratio 0.67, 95% CI 0.48 to 0.94; p = 0.020), with an increase in minor bleeding but remained as a net clinical benefit strategy. Those benefits were not present in patients without ST elevation (non-ST elevation ACS). The weighting and propensity analysis confirmed the same results. An interaction between pretreatment duration and bleeding was observed. In conclusion, pretreatment with clopidogrel reduced the occurrence of death and thrombotic outcomes at the cost of minor bleeding. Those benefits exclusively affected ST-elevation myocardial infarction cases. The potential benefit of routine upstream pretreatment in patients with non-ST-elevation ACS should be reappraised at the present.

Relation of contrast induced nephropathy to new onset atrial fibrillation in acute coronary syndrome

Chronic renal failure has been described as a risk factor for the development of atrial fibrillation (AF). The aim of this study was to examine the association between contrast-induced nephropathy (CIN) and new-onset AF in patients with acute coronary syndromes. A total of 1,520 consecutive patients (mean age 67.1 ± 12.7 years) with acute coronary syndromes (34.4% with ST-segment elevation myocardial infarctions) who underwent coronary angiography were studied. CIN was defined as an increase in serum creatinine of 0.5 mg/dl within 72 hours of contrast exposure. The independent effect of AF history (chronic or paroxysmal AF before catheterization) on the development of CIN, as well as the independent effect of CIN on the development of new-onset AF (after catheterization, during the in-hospital phase), were tested by using different logistic regression models. One hundred thirty-nine patients (9.1%) had histories of AF before catheterization (60 with paroxysmal and 79 with chronic AF), and 56 (4.1%) developed new-onset AF after catheterization. Eighty-seven patients (5.7%) had CIN. AF history was a predictor of CIN in univariate analysis (odds ratio 2.19, 95% confidence interval 1.22 to 3.95, p = 0.007) but not in multivariate analysis, after adjusting for confounding variables (odds ratio 1.69, 95% confidence interval 0.89 to 3.22, p = 0.111). In contrast, those with CIN had an increased prevalence of new-onset AF (15.3% vs 3.4%, p <0.001). After adjusting for those variables associated with new-onset AF in the univariate analysis, CIN continued to show a significant association with new-onset AF, with a twofold increased risk (odds ratio 2.45, 95% confidence interval 1.07 to 5.64, p = 0.035). In conclusion, the development of CIN is an independent predictor of new-onset AF in the context of acute coronary syndromes.

Long-term mortality of patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation for acute and stable coronary artery disease

BACKGROUND

Patients with atrial fibrillation (AF) are of increased risk for ischemic and bleeding complications, particularly when requiring aggressive antithrombotic therapy after coronary stenting. However, data from unselected patients on long-term mortality are scarce.

METHODS

We analyzed 2890 patients of a single-center registry undergoing coronary stenting between 2003 and 2012, of whom 1434 patients had stable coronary artery disease (CAD), while 1456 patients presented with acute coronary syndromes (ACS). As the primary endpoint, we compared long-term all-cause mortality between patients with AF and patients in sinus rhythm.

RESULTS

History or presence of AF was found in 146 (10.2%) patients with stable CAD and 93 (6.4%) patients with ACS. The median CHA2DS2-VASc scores were similar between stable CAD and ACS patients (4[2; 5] vs. 3[2; 5], p=0.92). Patients with AF had a significantly higher atherothrombotic risk profile and more co-morbidities. Patients undergoing PCI before 2011 received triple therapy (aspirin, clopidogrel and a vitamin K antagonist) in 25% of cases, compared to 64% of cases thereafter. Patients undergoing elective or urgent revascularization and suffering from AF had a similar 2-fold increased adjusted relative risk of death after a mean follow-up of 4.8 years (HR 1.95, 95% CI 1.27; 2.99, p<0.01 for stable CAD and HR 1.95, 95% CI 1.23; 3.11, p<0.01 for ACS).

CONCLUSION

In a general practice setting, patients with AF had significantly increased adjusted long-term mortality than patients without AF. After publication of the consensus document of different working groups of the European Society of Cardiology in 2010, triple therapy increased markedly.