Prognostic impact of newly diagnosed atrial fibrillation and episode characteristics in patients with acute coronary syndrome

Background/Introduction

Newly diagnosed atrial fibrillation (AF) frequently occurs during acute coronary syndrome (ACS). In contrast to known AF, little is known about the prognostic and therapeutic implications of new AF.

Purpose

To evaluate the prognostic impact of newly diagnosed and known AF in patients with ACS. Furthermore, we evaluated the association of episode characteristics of new AF with clinical outcomes: early vs late occurrence, short vs long duration, post-CABG occurrence, and OAC treatment.

Methods

This analysis was performed within the prospective, multicentre, FORCE-ACS registry which studies ACS patients in the Netherlands. All ECGs during index ACS admission were retrospectively examined for the occurrence of AF. Patients were classified as no, new, or known AF. New AF episodes were described regarding early or late occurrence, duration of the episode, and post-CABG occurrence, and OAC prescription at discharge was evaluated. The primary outcome was MACE, a composite of death, myocardial infarction and stroke. Secondary outcomes include the separate MACE components and bleeding. Crude and adjusted outcomes were evaluated by univariable and multivariable Cox regression.

Results

3902 patients were included of which 299 (10.2%) had new and 367 (9.4%) had known AF. Major adverse cardiac events happened significantly more in both new and known AF patients than in patients without AF (22.2%, 17.4%, and 9.2%, p<0.001). Ischemic stroke occurred significantly more in new AF but not in known AF patients, compared to patients without AF (3.5% vs 0.9% vs 1.1%). After one year follow-up, a total of 234 patients (6.3%) deceased, of whom 138 in the group without AF (4.6%), and significantly more in the groups with new AF (n=59, 15.9%), and known AF (n=37, 10.8%). The timing of onset of the AF episode showed no significant association with clinical outcomes. Longer duration of the episode, however, was associated with increased MACE (HR 2.0, 95% CI 1.2–3.1) and all-cause mortality (HR 2.0, 95% CI 1.2–3.4). Episodes of new AF that occurred post-CABG were associated with less MACE (HR 0.31, 95% CI 0.14–0.67) and all-cause mortality (HR 0.20, 95% CI 0.07–0.55). No significant association between OAC treatment and MACE nor any of its separate components was found.

Conclusion

Newly diagnosed atrial fibrillation in acute coronary syndromes is associated with worse clinical outcomes than known or no atrial fibrillation. Longer episodes were associated with worse outcomes than short episodes. Post-operative new AF was associated with better outcomes than non-post-operative new AF.

Funding Acknowledgement

Type of funding sources: None.

Radial crossover and unsuccessful radial access during coronary angiography or percutaneous coronary intervention: insights from the FORCE-ACS registry

Background

Radial crossover and unsuccessful radial access during coronary angiography or percutaneous coronary intervention (PCI) are associated with worse outcomes compared to successful radial access. The MATRIX score estimates the risk of radial crossover, but the predictive value of this novel risk score has not been evaluated in real-world acute coronary syndrome (ACS) patients.

Purpose

To evaluate (i) the temporal trends in the incidence for radial crossover and unsuccessful radial access, (ii) the reasons for unsuccessful radial access and (iii) the odds ratio for radial crossover and unsuccessful radial access in patients with a high MATRIX score.

Methods

Data from 4,514 ACS patients managed invasively and enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used. Radial crossover was defined as a failure to either start or complete coronary angiography or PCI via radial access and subsequent crossover to femoral or brachial access. Unsuccessful radial access was defined as failure to complete the procedure via radial access and crossover to the femoral or brachial access. Reasons for unsuccessful radial access were: (i) issues during puncture or sheath insertion, (ii) failure to complete angiography and (iii) failure to complete PCI. The odds ratio for radial crossover and unsuccessful radial access of patients with a high MATRIX score (≥41) compared to patients with a low score (<41) was calculated using logistic regression.

Results

The observed rate of radial crossover was 20.7%. The radial crossover rate decreased throughout the years from 38.8% to 14.8% as shown in Figure 1A. The most common reasons for radial crossover was that the operator did not choose radial access as the initial access site and proceed directly to a femoral or brachial approach (18.3% of all procedures). If radial access was attempted but ultimately unsuccessful (2.9% of all radial access attempts), the most common reasons were failure to start or complete coronary angiography and issues with atrial puncture or sheath insertion (Figure 1B). Failure to complete PCI after successfully coronary angiography was rare. The rate of unsuccessful radial access relative to all radial access attempts was consistent over time between 1.8% and 4.2%. Patients with a high MATRIX score had a fourfold higher risk of radial crossover as compared to patients with a low score (odds ratio 4.07, 95%-CI: 3.47–4.78) and an almost twofold risk of unsuccessful radial access (odds ratio 1.87, 95%-CI: 1.19–2.93) (Figure 2).

Conclusion

The incidence of radial crossover declined throughout the years, while the rate of unsuccessful radial access was consistent over time. The MATRIX score is able to identify patients at higher risk of radial crossover and unsuccessful radial access.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The FORCE-ACS registry is supported by grants from ZonMw, the St. Antonius Research Fund and AstraZeneca.

Effects of CYP3A4*22 carrier and CYP3A5 expressor status on clinical outcome in patients treated with ticagrelor for acute coronary syndrome

Background

Current guidelines recommend using ticagrelor in patients with acute coronary syndrome. Ticagrelor is predominantly metabolized by CYP3A4 and to a lesser extent by CYP3A5. CYP3A4*22 allele and the CYP3A5 expressor status influence the metabolization of ticagrelor, increasing plasma concentration and platelet inhibition. Nevertheless, little is known about the impact of the CYP3A4*22 allele or CYP3A5 expressor status on clinical outcomes in ticagrelor treated patients.

Purpose

Our study aims to assess the effects of the CYP3A4*22 allele and CYP3A5 expressor status in patients with STEMI and treated with ticagrelor, with regards to clinical outcomes and the clinical side-effect dyspnea.

Methods

Patients from the POPular Genetics trial treated with ticagrelor were genotyped for the CYP3A4*22 and CYP3A5*3 alleles. Patients were divided into two groups based on their CYP3A4 (*22 carriers vs. *22 non carriers) and CYP3A5 status (expressor vs. non-expressors). The primary thrombotic endpoint was a composite of cardiovascular death, myocardial infarction, definite stent thrombosis and stroke. The primary bleeding outcome consisted of PLATO major and minor bleeding. The key secondary endpoint was clinically relevant dyspnea. The follow-up duration was one year.

Results

A total of 1,281 patients with ST-elevation myocardial infarction (STEMI) were used for the analyses. In the first analysis, CYP3A4*22 carriers (n=152) versus CYP3A4*22 non-carriers (n=1,129) were not found to have a significant correlation with the primary thrombotic outcome (1.3% vs. 2.5% adjusted hazard ratio 1.81 [0.43–7.62]) or the primary bleeding outcome (13.2% vs. 11.3% adjusted hazard ratio 0.93 [0.58–1.50]) (See Figure 1 and 2). CYP3A5 expressors (n=196) versus non-expressors (n=926) did not show a significant difference for the primary thrombotic outcome (2.6% versus 2.5% adjusted hazard ratio 1.03 [0.39–2.71] or the primary bleeding outcome (12.8% versus 10.9% adjusted hazard ratio 1.13 [0.73–1.76]). With respect to dyspnea, no significant difference was observed between CYP3A4*22 carriers versus CYP3A4*22 non-carriers 44.0% vs. 45.0%, risk ratio 1.04 [0.45–2.42] or CYP3A5 expressors versus CYP3A5 non-expressors 35.3% versus 47.8% risk ratio 0.60 [0.27–1.30].

Conclusions

In STEMI patients treated with ticagrelor, CYP3A4*22 carriers and CYP3A5 expressors did not affect clinical outcomes with regards to thrombotic events, bleeding rate, or the side-effect dyspnea.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Netherlands Organization for Health Research and Development (ZonMW). The authors are solely responsible for designing and conducting this study, conducting all study analyses, and drafting and editing the manuscript and its final contents.

The risk-treatment paradox in acute coronary syndrome patients: insights from the FORCE-ACS registry

Background

Acute coronary syndrome (ACS) patients at high risk might benefit most from guideline-recommended interventions. However, it is well recognized that the delivery of guideline-directed care is inversely related to the estimated mortality risk, the so called risk-treatment paradox.

Purpose

To assess the existence of the risk-treatment paradox in a contemporary cohort of ACS patients and its possible association with one-year mortality.

Methods

The study population consisted patients enrolled in the FORCE-ACS registry who survived their initial admission. All ACS patients were stratified into low, intermediate or high mortality risk based on the Global Registry of Acute Coronary Events (GRACE) risk score. Optimal guideline-recommended care was defined as undergoing coronary angiography during initial hospital admission and receiving all outpatient medications with a class I guideline recommendation (i.e. aspirin, P2Y12-inhibitor, beta-blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and cholesterol-lowering drug). Aspirin and/or a P2Y12-inhibitor on top of an oral anticoagulant was also considered as optimal guideline-recommended care. The cumulative incidence of one-year mortality between optimal and suboptimal managed patients, within each GRACE risk score stratum, was estimated.

Results

In total, 2,524 patients who were enrolled between January 2015 and June 2018 were included. Based on the GRACE risk score, 46.9% of patients were classified as low-risk, 37.6% as intermediate-risk and 15.5% as high-risk. Overall, 49.8% of patients received optimal guideline-recommended care. Among the different risk strata, 54.9% of the low-risk, 49.1% of the intermediate-risk and 36.1% of the high-risk patients received optimal guideline-recommended care (Table 1).

DAPT or DAT treatment (95.3% overall) did not differ between the risk categories. Beta-blockers were prescribed less frequently (69.6% overall), butprescription rates did not differ between the risk categories. ACE-inhibitors/ARBs were prescribed in 74.1% of all patients, but less often in high risk patients. Cholesterol lowering-drugs were prescribed in almost all patients (94.9% overall), but less frequently in high risk patients. Overall, 93.9% of patients underwent coronary angiography (CAG), high-risk patients had a statistically significant lower likelihood of undergoing CAG. In all risk categories, optimal guideline-recommended care was associated with a lower one-year mortality as compared to sub-optimal treatment (5.7% vs. 15.6% in high-risk) (Fig. 1).

Conclusion

Patients at higher estimated mortality risk, based on the GRACE-risk score, are less likely to receive guideline-recommended care. Although, the absolute benefit from guideline-recommended care appears to be greater in high-risk patients. Receiving guideline-recommended care was associated with a statistically significant better prognosis in intermediate- and high-risk patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMW Netherlands TopZorgSt. Antonius Research funds Figure 1. All-cause mortality

External validation of the Global Registry of Acute Coronary Events (GRACE) risk score: insights from the FORCE-ACS registry

Background

Acute coronary syndrome (ACS) patients are a heterogeneous group with a varying risk of in-hospital and long-term mortality. Clinical risk scores play an important role in estimating these risks. Among the available risk scores, the Global Registry of Acute Coronary Events (GRACE) risk score is most used in routine clinical practice. Given the temporal improvements in both the in-hospital and long-term survival for ACS patients, continued validation of the GRACE risk score in contemporary patient cohorts is warranted. Moreover, the performance of the GRACE risk score in important subgroups with specific risk profiles has received limited attention.

Purpose

To assess the performance of the GRACE risk score for predicting in-hospital and one-year mortality in a contemporary, unselected cohort of ACS patients.

Methods

The study population consisted of ACS patients enrolled in the FORCE-ACS registry. To assess model discrimination, c-statistics were computed from the area under the receiver operator characteristic curve. Calibration was visually assessed by plotting observed versus predicted mortality and tested using the Hosmer-Lemeshow goodness-of-fit test. Indices of calibration and discrimination were also assessed in subgroups based on sex, age, type of ACS and bleeding risk (according to the PRECISE-DAPT score).

Results

In total, 2,587 ACS patients (median age 68 years, 28.4% women) who were enrolled in the FORCE-ACS registry between January 2015 and June 2018 were used for model validation. The in-hospital and one-year mortality rates were 2.4% and 6.3%, respectively. The discriminative ability of the GRACE risk score was good for in-hospital mortality (c-statistic 0.87, 95% CI: 0.82–0.91) and one-year mortality (c-statistic 0.82, 95% CI: 0.78–0.85) (Figure 1). The GRACE risk score predicted one-year mortality less well in patients at high risk of bleeding (c-statistic 0.68 vs. 0.78 in patients at low risk of bleeding, p=0.04). We did not observe statistically significant differences in discrimination for predicting in-hospital or one-year mortality between other subgroups. In the overall cohort, calibration of the GRACE risk score for in-hospital morality was adequate (Hosmer-Lemeshow test: p=0.11), but the GRACE risk score overestimated the in-hospital mortality risk in patients <75 years and patients at low risk of bleeding (Figure 2). The GRACE risk score overestimated the one-year mortality risk (Hosmer-Lemeshow test: p<0.01) in the overall cohort, particularly in patients <75 years, men and patients at low risk of bleeding (Figure 2).

Conclusion

The GRACE risk score remains a useful tool for predicting in-hospital and one-year mortality, although absolute risk at one year might be overestimated in contemporary ACS patients.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The FORCE-ACS registry is supported by grants from ZonMw, the St. Antonius Research Fund and AstraZeneca Figure 1. Discrimination of the GRACE risk scoreFigure 2. Calibration of the GRACE risk score

Autonomic dysfunction in ICU-acquired weakness: a prospective observational pilot study

PURPOSE

Intensive care unit-acquired weakness (ICU-AW) is a frequent complication of critical illness. It is unknown if patients with ICU-AW also have autonomic dysfunction, another frequent neurological complication of critical illness. We hypothesized that patients who develop ICU-AW also develop autonomic dysfunction. Furthermore, we hypothesized that patients with ICU-AW are more prone to develop autonomic dysfunction compared to patients without ICU-AW.

METHODS

This was an observational cohort study of patients newly admitted to the ICU. Autonomic dysfunction was measured daily using heart rate variability (HRV) to a maximum of 15 days after admission. ICU-AW was diagnosed using the Medical Research Council score. Abnormal HRV was defined using age-matched reference values. The association between ICU-AW and HRV was analyzed using linear mixed effects models.

RESULTS

We included 83 patients, 15 (18 %) of whom were diagnosed with ICU-AW. Of 279 HRV measurements, 204 could be analyzed. Abnormal HRV was found in all critically ill patients irrespective of the presence of ICU-AW (ICU-AW 100 % (IQR 71-100) vs. no ICU-AW 100 % (IQR 40-100); p = 0.40). Mechanical ventilation, sedation, norepinephrine, heart rate, and HRV artifacts were identified as confounders for HRV. ICU-AW was not associated with HRV.

CONCLUSION

Abnormal HRV is frequent in critically ill patients, both with and without ICU-AW. It is unlikely that patients with ICU-AW are more prone to develop abnormal HRV. However, we found that abnormal HRV may not be an accurate indicator of autonomic dysfunction because of confounders.