Original article

Prognostic role of atrial fibrillation in acute coronary syndromes: a real-life, contemporary analysis

DOI: https://doi.org/10.4414/cvm.2020.02123
Publication Date: 12.09.2020
Cardiovasc Med. 2020;23:w02123

Adjibodou Borisa, Biasco Luigib, Marcon Serenaa, Svab Stefanoa, Chiodini Alessandraa, Pasotti Elenaa, Moccetti Tizianoa, Moccetti Marcod, Klersy Catherinec, Pedrazzini Giovannie

a Fondazione Cardiocentro Ticino, Lugano, Switzerland

b Department of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland and Division of Cardiology, Azienda Sanitaria Locale Torino, Italy

c Service of Clinical Epidemiology and Biometry, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy

d Division of Cardiology, Kantonsspital Aarau, Aarau, Switzerland

e Fondazione Cardiocentro Ticino and Department of Biomedical Science, Università della Svizzera Italiana, Lugano, Switzerland

Summary

OBJECTIVES

To analyse the impact of atrial fibrillation (AF) on in-hospital mortality and the role of antithrombotic regimens on 1-year outcomes in patients presenting acute coronary syndrome (ACS) and AF over a 4-year period in a Swiss tertiary referral centre.

METHODS

Between 2011 and 2014, in-hospital mortality of ACS patients in AF was compared to that observed for ACS patients in sinus rhythm. Major adverse cardiovascular events (MACE) and major bleeding were analysed at 1 year according to the antithrombotic regimen at discharge.

RESULTS

Out of the 2234 ACS patients, 187 (8.4%) presented with AF, either at admission (54%) or during the hospital stay (46%). In-hospital mortality was higher in ACS-AF cohort than in ACS patients in sinus rhythm (7.5 vs 4.1%; odds ratio [OR] 1.89, 95% confidence interval [CI] 1.06–3.38; p = 0.039). After adjustment for age and ACS presentation, AF did not appear to represent an independent risk factor for in-hospital mortality in ACS patients (OR 1.44, 95% CI 0.78–2.65; p = 0.25). Through combination of the type of ACS and presence of AF, in-hospital mortality was stratified into four risk categories: low (non-ST-segment elevation myocardial infarction [NSTEMI] without AF); intermediate (NSTEMI with AF; OR 3.25, 95% CI 1.017–9.09]); high (ST-segment-elevation myocardial infarction [STEMI] without AF; OR 5.12, 95% CI 2.93–8.95) and very high risk (STEMI with AF; OR 8.62, 95% CI 3.63–20.48). MACE or major bleedings did not differ according to antithrombotic regimens at discharge.

CONCLUSION

AF is common in the ACS setting and associated with increased risk of in-hospital mortality. Although AF did not represent an independent prognosticator in ACS, a progressive increase on in-hospital death was observed when combining type of ACS and presence/absence of AF.

Keywords: : acute coronary syndrome, atrial fibrillation, mortality, antithrombotic regimen

Introduction

The increasing incidence of atrial fibrillation (AF) in western countries represents a medical, social and economic challenge owing to its impact on prognosis, quality of life and healthcare costs. The clinical relevance of AF becomes even more crucial when it is associated with acute coronary syndromes (ACS). In fact, up to 10% of patients with ACS may present with concomitant AF either evident at admission or occurring during the hospitalisation.

Whether AF per se adversely affects prognosis in ACS or is merely a marker of comorbidities that effectively drive the outcome is still widely debated; nonetheless the poor outcome of patients presenting both conditions is well established [16].

The onset of AF in ACS patients is associated with higher mortality rates [79] and represents a therapeutic concern because of need to manage the thrombotic and ischaemic risk (by means of anticoagulants and platelet inhibitors) and to avoid haemorrhagic complications.

Despite being a common clinical situation with substantial impacts on outcome and clinical management, little is known about different management strategies and their related impact on outcomes in AF-ACS patients. Available data derive from post hoc analyses of randomised trials (neither focused nor powered to answer this issue) or from international registries [812]. As a result of this lack of medical evidence, current guidelines recommend an empirical approach aiming at individualising medical management. Recent expert consensus documents by the European Society for Cardiology (ESC) and guidelines by Canadian Society of Cardiology support this approach in clinical practice [1317].

In the light of the complexity associated with the management of this clinical scenario, we aimed at analysing the impact of AF on in-hospital mortality of ACS patients and the impact of antithrombotic regimens on 1-year outcomes in patients admitted for an ACS associated with AF over a 4-year period in a tertiary referral centre in Switzerland.

Methods

Study population

Clinical and administrative records including survival data at discharge of all patients admitted at our institution for ACS [18] between January 2011 and December 2014 were reviewed. Medical data from patients presenting with AF [19] either at admission (without further differentiation into paroxysmal, persistent, permanent) or at discharge were analysed with respect to clinical and angiographic characteristics. According to a twelve-lead ECG, clinical symptoms and sensitive troponin I, patients were divided into two groups: (1) patients presenting with typical symptoms and ST-segment elevation (STEMI) and/or left bundle branch block and treated by urgent/emergency percutaneous coronary intervention (PCI) and (2) patients with ACS classified as non-ST-segment elevation myocardial infarction (NSTEMI) and scheduled for an invasive approach within 48–72 hours. Preloading regimens and periprocedural antithrombotic treatments were administered according to local guidelines and to the clinical context. Survival status, occurrence of cardiac death, myocardial infarction, definite stent thrombosis, target vessel revascularisation, ischaemic stroke and clinically relevant major bleeding were determined at discharge and 1 year. Moreover, the 1-year outcome according to the antithrombotic and antiplatelet regimen prescribed at discharge was also analysed. In order to evaluate the relationship between medical management and outcome, the entire population was split into three subgroups: (1) patients discharged on dual antiplatelet therapy (DAPT); (2) patients discharged on single antiplatelet therapy + oral anticoagulation (SAPT + OAC); and (3) patients discharged on a triple antithrombotic regimen (DAPT + OAC).

Endpoints

In-hospital mortality was determined and compared with that observed in the cohort of ACS patients without AF admitted in the same time span (between January 2011 and December 2014). Major adverse cardiovascular event (MACE) at 1 year was a composite endpoint including cardiac death, myocardial infarction, definite stent thrombosis, target vessel revascularisation and ischaemic stroke [20]. Clinically relevant major bleedings at 1 year were defined according to the Bleeding Academic Research Consortium (BARC) definition [21]. Life status and clinical events were ascertained at 12 months by telephone contact in all patients.

Statistical analysis

Data are described as mean ± standard deviation (SD) when continuous and count and percentage (%) when categorical. Comparisons between treatment groups were performed with the Kruskall-Wallis test and the Fisher exact test, as appropriate. Logistic regression was used to assess the association of AF and in-hospital death, while adjusting for a series of predefined risk factors (age, gender and ACS presentation). Odds ratios (ORs) and 95% confidence intervals (CIs) were also reported. The interaction of AF and ACS presentation was tested and, given the clinical relevance, the effect of AF was presented separately for ACS-STEMI and ACS-NSTEMI. Median follow-up (25th–75th percentiles) was computed with the inverse Kaplan-Meier method. Kaplan-Meier event-free survival curves were plotted. The log-rank test was used to compare event-free survival between treatment groups. The hazard ratio (HR) and 95% CI was computed from a Cox model. To account for confounding, inverse probability weight when fitting the model was used. This weight was computed as the inverse of the probability of being treated with triple therapy and was derived from a logistic model including 16 demographic and clinical characteristics. The p-score command in Stata was used, with the common support option and the logit link. Stata 14.1 (Stata Corp, College Station, TX, USA) was used for computation. A two-sided p-value <0.05 was considered statistically significant. For post-hoc comparisons between treatment groups, significance was set at 0.017 (according to the Bonferroni correction).

Results

ACS-AF patients’ characteristics

Between January 2011 and December 2014, 2234 consecutive patients were admitted for ACS (fig. 1): 1097 (49.1%) with STEMI and 1137 (50.9%) with NSTEMI. Of these, 187 (8.4%) presented with concomitant AF either evident at admission (n = 101, 54%) or occurring during the hospital stay (n = 86, 46%). Table 1 reports the clinical characteristics and acute management strategies in the ACS-AF cohort. In this group, 121 (64.5%) were treated by PCI/stenting, 14 (7.5%) underwent surgical revascularisation and 52 (28%) were medically managed.

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Figure 1
Acute coronary syndrome (ACS) undergoing percutaneous intervention (PCI) between 2011 and 2014 in Canton Ticino. 8.4% (n = 187) of ACS patients presented with concomitant atrial fibrillation (AF). In a subgroup of patients (n = 156) three antithrombotic regimens (triple therapy; SAPT + OAC; DAPT) were compared with respect to the predefined endpoints.

Table 1

Characteristics of the entire cohort of ACS patients presenting concomitant atrial fibrillation.

 ACS-AF cohort
Number187
Age (years)74 ± 11
Female (%)31
ACS STEMI (%)43.8
ACS NSTEMI (%)56.2
Cardiogenic shock (%)10.7
New onset AF (%)46
CHADS2-VASC score4.1 ± 1.5
HAS-BLED score3 ± 1.2
LVEF (%)46 ± 12.5
Radial access (%)19.5
Acute treatment 
– PCI (%)64.5
– CABG (%)7.5
– Medical (%)28

ACS = acute coronary syndrome; AF = atrial fibrillation; CABG = coronary artery bypass graft; LVEF = left ventricular ejection fraction; NSTEMI = non-ST-segment elevation myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction

In-hospital mortality and its predictors

The rate of in-hospital mortality was higher in ACS-AF cohort (14/187) as compared with ACS patients in sinus rhythm (SR) (84/2047) and this difference was statistically significant (7.5 vs 4.1%; OR 1.89, 95% CI 1.06–3.38; p = 0.039). The highest in hospital mortality was observed in the AF-STEMI group (11.4 vs 7.1% for STEMI patients in sinus rhythm [SR]; p 0.17), whereas the lowest was detected in the NSTEMI-SR group (1.7 vs 4.6% for NSTEMI-AF, p = 0.034) (fig. 2); no interaction between AF and ACS presentation was observed (p = 0.28). After adjustment for age and ACS presentation, AF did not appear to represent an independent prognostic risk factor for in hospital mortality in ACS patients (OR 1.44, 95% CI 0.78–2.65; p = 0.25) (Table 2).

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Figure 2
In-hospital mortality in the population with acute coronary syndrome according to the rhythm at presentation (AF = atrial fibrillation, SR = sinus rhythm). * Fisher exact test. NSTEMI = non-ST-segment elevation myocardial infarction; STEMI = ST-segment elevation myocardial infarction

Table 2

Predictors of in-hospital mortality in ACS patients; logistic regression model with atrial fibrillation and confounding factors such as ACS presentation (ST+/ST–), sex (female or male), age. After adjustment for age and ACS presentation AF do not appear as an independent prognostic factor of mortality in ACS patients.

MortalityOR95% CIp-value
AF−
AF+
1.00 (base)
1.44

(0.78–2.65)

0.246
ST−
ST+
1.00 (base)
5.56

(3.38–9.15)

0.0001
Sex female
Sex male
1.00 (base)
1.03

(0.65–1.64)

0.887
Age, per year1.06(1.04–1.08)0.0001

ACS = acute coronary syndrome; AF = atrial fibrillation; CI = confidence interval; OR = odds ratio; ST = ST-segment elevation

Through combination of the type of ACS (STEMI vs NSTEMI) and the presence of AF, in-hospital mortality was stratified into four risk categories: low risk (OR 1, reference: NSTEMI without AF); intermediate risk (OR 3.25, 95% CI 1.017–9.09; p = 0.0171: NSTEMI with AF); high risk (OR 5.12, 95% CI 2.93–8.95: STEMI without AF) and very high risk (OR 8.62, 95% CI 3.63–20.48, p <0.00001: STEMI with AF) (fig. 3).

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Figure 3
Forrest plot demonstrating stratification of in-hospital mortality in 4 categories: low risk (yellow), intermediate risk (grey), high risk (orange), very high risk (blue). *odds ratio, **confidence interval, *** Fisher exact test. AF = atrial fibrillation; NSTEMI = non-ST-segment elevation myocardial infarction; STEMI = ST-segment elevation myocardial infarction

One-year Follow up

One hundred and seventy-three patients were discharged alive after an ACS with concomitant AF. Of these, 17 (9.83%) were discharged on SAPT or only OAC and were therefore excluded from our analysis. The remaining 156 patients were divided according to their medical treatment into three regimen groups: (1) patients on DAPT (n = 88, 56.4%); (2) patients on SAPT + OAC (n = 23, 14.7%); and (3) patients on a triple antithrombotic regimen DAPT + OAC (n = 45, 28.9%).

No differences in clinical presentation were observed between the groups (table 3) except for age (with a progressive decrease from triple to SAPT+OAC and DAPT, p = 0.037) and treatment with PCI (highest in patients receiving DAPT, lowest in SAPT+OAC; p = 0.039) as well as referral for surgical revascularisation (highest in SAPT+OAC; p <0.001).

Table 3

Clinical characteristics of the three groups of patients defined according to the antithrombotic regimen.

 Triple therapySAPT + OACDAPTp-value
Number452388-
Age (years)77 ± 776 ± 1171 ± 120.04
Gender female (%)31.321.732.70.65
STEMI/NSTEMI (%)33.3/66.739.1/60.950/500.14
Cardiogenic shock (%)6.31313.30.42
New onset AF (%)41.760.942.90.27
CHADS2-VASC score4± 1.54.7± 1.94.1± 1.60.24
HAS-BLED score3 ± 1.33.1 ± 12.9 ± 1.30.64
LVEF (%)47 ± 12.343 ± 9.846 ± 13.10.35
Radial access (%)20.88.721.40.41
Acute treatment    
– PCI, n (%)34 (75.6)11 (47.8)62 (70.5)0.04
– CABG, n (%)0 (0)6 (26.1)2 (2.2)0.001
– Medical, n (%)11 (24.4)6 (26.1)24 (27.3)0.94

AF = atrial fibrillation; CABG = coronary artery bypass graft; DAPT = dual antiplatelet therapy; LVEF = left ventricular ejection fraction; NSTEMI = non-ST-segment elevation myocardial infarction; OAC = oral anticoagulant; PCI = percutaneous coronary intervention; SAPT = single antiplatelet therapy; STEMI = ST-segment elevation myocardial infarction; triple therapy = OAC + aspirin + clopidogrel
Age and scores were represented as mean value ± standard deviation. The others parameters were represented in percentages.

Ten deaths occurred over a median follow-up of 15 months (25th–75th percentiles 12–27), corresponding to a mortality rate of 4.0 per 100 person-years (95% CI 2.1–7.4). Among this population of ACS with concomitant AF, 118 patients (75.6%) were discharged in sinus rhythm and 38 (24.4%) remained in AF. One-year survival did not differ among patients discharged in sinus rhythm or AF (p = 0.65). Mortality among the three groups was comparable (p = 0.31; table 4).

Table 4

One-year outcomes (death, MACE and major bleeding events) according to the antithrombotic regimen.

1-year outcomesTriple therapy
n = 45
AOC + SAPT
n = 23
DAPT
n = 88
p-value*
Death
n; HR; 95% CI
n = 3
HR = 1.48
95% CI 0.33–6.63
n = 3
HR = 3.06
95% CI [0.68 -13.67]
n = 4
HR = 1 (base)
0.31
MACE
n; HR; 95% CI
n = 7
HR = 1.95
95% CI 0.68–5.51
n = 3
HR = 1.83
95% CI [0.47 -7.10]
n = 7
HR = 1 (base)
0.41
Major bleeding
n; HR; 95% CI
n = 5
HR = 1.68
95% CI 0.51–5.50
n = 0

n = 6
HR = 1 (base)
0.27

CI = confidence interval; DAPT = dual antiplatelet therapy; HR = hazard ratio; MACE = major adverse cardiovascular event; OAC = oral anticoagulant (oral vitamin K antagonist); SAPT = single antiplatelet therapy; triple therapy = OAC + aspirin 100 mg + clopidogrel 75 mg
* p-value estimated with log-rank test.

MACE occurred more frequently in the group on the triple therapy regimen (n = 7/45; 15.6%) with a HR of 1.93 (95% CI 0.68–5.51) than the group discharged on SAPT + OAC (HR = 1.83, 95% CI 0.47–7.10). However, no statistically significant differences were observed between the three group (p = 0.41; table 4).

Major Bleeding

Major bleeding occurred more frequently in the triple therapy group (n = 5/45, 11.1%) as compared with the SAPT+OAC group (none observed) and DAPT group (n = 6/88, 6.8%). However, no statistically significant difference were observed between the groups (HR 1.68 for triple therapy, 95% CI 0.51–5.50; p = 0.27).

Univariable analysis and adjustment using propensity score inverse weighting for event prediction at 12 months (death, MACE, major bleeding) did not reveal any statistically significant difference between the groups. The results are reported in table 5.

Table 5

One-year outcomes (survival, MACE and major bleeding events) according to the antithrombotic regimen after adjustment for confounding factors (ACS presentation ST+/ST−; sex; age).

1 year outcomesTriple therapy
n = 45
OAC + SAPT
n = 23
DAPT
n = 88
p-value*
Deaths
HR; 95% CI
HR = 2.68
95% CI 0.39–18.51
HR = 3.66
95% CI 0.44–30.26
HR = 1 (base)0.44
MACE
HR; 95% CI
HR = 3.41
95% CI 0.93–12.45
HR = 1.52
95% CI 0.25–9.20
HR = 1 (base)0.17
Major bleeding
HR; 95% CI
HR = 2.33
95% CI 0.64–8.52

HR = 1 (base)0.13

ACS = acute coronary syndrome; CI = confidence interval; DAPT = dual antiplatelet therapy; HR = hazard ratio; MACE = major adverse cardiovascular event; OAC = oral anticoagulant (oral vitamin K antagonist); SAPT = single antiplatelet therapy; ST = ST-segment elevation; triple therapy = OAC + aspirin 100 mg + clopidogrel 75 mg
* p-value estimated with weighting propensity score.

Discussion

The present analysis represents a real life snapshot of the clinical characteristics and outcomes of contemporary patients admitted with ACS associated with AF in a tertiary western PCI centre.

Some important considerations may be drawn out from our data:

  • The presence of atrial fibrillation in the clinical context of an ACS should be regarded as a red flag identifying those patients at higher risk of in-hospital mortality.
  • An interplay between presence/absence of AF and ACS clinical presentation (NSTEMI vs STEMI) was clearly evident from a prognostic perspective.
  • Owing to the lack of significance after multivariable analysis (adjustment for ACS type and age), the role of AF as an independent prognosticator in ACS remains elusive.

In our study, the cumulative prevalence of AF in the clinical context of ACS was 8.4%. This result is in line with those of other large registries [16, 22, 23], as well as to those reported by the AMIS plus (Swiss national registry of myocardial infarction). In the international Global Registry of Acute Coronary Events Study (GRACE registry) including 59,032 ACS patients between 2000 and 2007, authors reported a history of AF in 7.6% of the cohort and a rate of new-onset of the arrhythmia (deemed related to the ACS) in 5.3% of patients. This represent a cumulative prevalence of 12.9% [22]. In the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry including 69,255 patients with ACS, the prevalence of previous AF weeks before the index ACS event was 7.1% [23].

The presence of AF is known to be associated with increased mortality [24], but its real impact in ACS is subject to debate. Whether AF per se adversely affects prognosis in ACS or should be considered as a marker of comorbidities, the latter effectively driving the outcome, is still largely unclear [16].

In line with previous studies and with current clinical knowledge, our data show that in-hospital mortality is significantly higher for AF patients. Moreover, we confirmed that an interaction exists between the clinical presentation as STEMI vs NSTEMI and the arrhythmia, which is in line with results reported by Angeli et al. in a previous meta-analysis [25] and those derived from the GRACE registry by Mehta et al. In this sub-analysis of GRACE registry, authors concluded that previous and new-onset AF are associated with increased hospital morbidity and mortality [26]. We were able to stratify in-hospital mortality into four categories of risk: low risk (NSTEMI without AF); intermediate risk (NSTEMI with AF); high risk (STEMI without AF) and very high risk (STEMI with AF). Our data complete the results of Poçi et al., which showed that AF in patients with ACS should be regarded as an important risk factor irrespective of its presentation because there was no difference on long-term mortality (10 years) between the groups according to the type of AF [27]. A recent analysis derived from the nationwide Swiss AMIS plus registry further supported this finding [28]. However, in our study AF did not appear to be a supplementary independent prognostic risk factor of in-hospital mortality in ACS, indicating to the elusive role of AF in this setting.

In real life, STEMI patients benefit from an aggressive and urgent approach to management. Our data are hypothesis-generating and we speculate whether an analogous approach should be used in NSTEMI patients with previous or new-onset AF, on the basis of the detrimental effect of the arrhythmia on in-hospital mortality. Different risk scores are available to predict death or myocardial infarction following an initial ACS (GRACE 2.0 score, AMIS risk score), but none of them mention AF as a risk marker in the prediction of in-hospital death [28, 29]. Although larger prospective studies are needed to confirm our data, it seems necessary, from a clinical standpoint, to include AF as an essential variable in estimates of in-hospital mortality in ACS patients.

Several limitations should be mentioned to put our data in context. Our study was observational, retrospective, longitudinal and single-centre, and therefore has the intrinsic limitations of this study design. Despite the long time span of 4 years, the number of patients included in our analysis was small and data on several comorbidities (chronic obstructive pulmonary disease, hypertension, kidney failure, heart failure) were not available. Consequently, the number of events at follow up are few and do not allow any definite conclusion when outcome data are compared especially because our analysis was carried out before the results of the four major trials comparing dual antiplatelet plus a direct acting oral anticoagulant vs triple antithrombotic treatment in patients with AF (PIONEER-AF-PCI, RE-DUAL PCI, AUGUSTUS and ENTRUST-AF-PCI) were available [3034]. We also note that 75.6% of patients with AF were discharged in sinus rhythm. Unfortunately, as a result of the missing data, we were not able to ascertain whether a spontaneous conversion occurred or an intervention (pharmacological or electrical) was performed in order to restore the rhythm control. No patient was treated with catheter ablation.

Conclusion

AF is common in the setting of ACS and is associated with an increased risk of in-hospital mortality. Although it seems not to have a supplementary independent prognostic effect in ACS after adjustment for confounding factors, AF should nonetheless be added as a parameter for scoring in-hospital mortality in the acute setting of ACS due to a gradual increase of in-hospital mortality with the combination of AF and any ACS presentation.

Disclosure statement

No financial support and no conflict of interest relevant to this article was reported.

Correspondence

Prof. Giovanni Pedrazzini, MD, Head of the Cardiological Department, Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, giovanni.pedrazzini[at]cardiocentro.org

References

1 Al Khdair D, Alshengeiti L, Elbarouni B, Yan RT, Grondin FR, Spencer FA, et al.; Global Registry of Acute Coronary Events (GRACE/GRACE2) and the Canadian Registry of Coronary Events (CANRACE) Investigators. Management and outcome of acute coronary syndrome patients in relation to prior history of atrial fibrillation. Can J Cardiol. 2012;28(4):443–9. doi:. http://dx.doi.org/10.1016/j.cjca.2011.12.011 PubMed

2 Rathore SS, Berger AK, Weinfurt KP, Schulman KA, Oetgen WJ, Gersh BJ, et al.Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation. 2000;101(9):969–74. doi:. http://dx.doi.org/10.1161/01.CIR.101.9.969 PubMed

3 Schmitt J, Duray G, Gersh BJ, Hohnloser SH. Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications. Eur Heart J. 2009;30(9):1038–45. doi:. http://dx.doi.org/10.1093/eurheartj/ehn579 PubMed

4 Lau DH, Huynh LT, Chew DP, Astley CM, Soman A, Sanders P. Prognostic impact of types of atrial fibrillation in acute coronary syndromes. Am J Cardiol. 2009;104(10):1317–23. doi:. http://dx.doi.org/10.1016/j.amjcard.2009.06.055 PubMed

5 Podolecki T, Lenarczyk R, Kowalczyk J, Kurek T, Boidol J, Chodor P, et al.Effect of type of atrial fibrillation on prognosis in acute myocardial infarction treated invasively. Am J Cardiol. 2012;109(12):1689–93. doi:. http://dx.doi.org/10.1016/j.amjcard.2012.02.009 PubMed

6 González-Pacheco H, Eid-Lidt G, Altamirano-Castillo A, Álvarez-Sangabriel A, González-Hermosillo A, Meléndez-Ramírez G, et al.Prevalence and prognostic implications of different types of atrial fibrillation in patients admitted to a coronary care unit. Int J Cardiol. 2014;172(2):e379–81. doi:. http://dx.doi.org/10.1016/j.ijcard.2013.12.291 PubMed

7 Lopes RD, Pieper KS, Horton JR, Al-Khatib SM, Newby LK, Mehta RH, et al.Short- and long-term outcomes following atrial fibrillation in patients with acute coronary syndromes with or without ST-segment elevation. Heart. 2008;94(7):867–73. doi:. http://dx.doi.org/10.1136/hrt.2007.134486 PubMed

8 Rubboli A, Schlitt A, Kiviniemi T, Biancari F, Karjalainen PP, Valencia J, et al.; AFCAS Study Group. One-year outcome of patients with atrial fibrillation undergoing coronary artery stenting: an analysis of the AFCAS registry. Clin Cardiol. 2014;37(6):357–64. doi:. http://dx.doi.org/10.1002/clc.22254 PubMed

9 Rene AG, Généreux P, Ezekowitz M, Kirtane AJ, Xu K, Mehran R, et al.Impact of atrial fibrillation in patients with ST-elevation myocardial infarction treated with percutaneous coronary intervention (from the HORIZONS-AMI [Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction] trial). Am J Cardiol. 2014;113(2):236–42. doi:. http://dx.doi.org/10.1016/j.amjcard.2013.09.016 PubMed

10 Rubboli A, Sciahbasi A, Briguori C, Saia F, Palmieri C, Moroni LA, et al.; WARfarin and coronary STENTing registry. In-hospital management and outcome of patients on warfarin undergoing coronary stent implantation: results of the multicenter, prospective WARfarin and coronary STENTing (WAR-STENT) registry. J Invasive Cardiol. 2013;25(4):170–6. PubMed

11 Lamberts M, Gislason GH, Olesen JB, Kristensen SL, Schjerning Olsen AM, Mikkelsen A, et al.Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol. 2013;62(11):981–9. doi:. http://dx.doi.org/10.1016/j.jacc.2013.05.029 PubMed

12 Pilgrim T, Kalesan B, Zanchin T, Pulver C, Jung S, Mattle H, et al.Impact of atrial fibrillation on clinical outcomes among patients with coronary artery disease undergoing revascularisation with drug-eluting stents. EuroIntervention. 2013;8(9):1061–71. doi:. http://dx.doi.org/10.4244/EIJV8I9A163 PubMed

13 Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, et al.; Authors/Task Force members. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35(37):2541–619. doi:. http://dx.doi.org/10.1093/eurheartj/ehu278 PubMed

14 Lip GYH, Collet JP, Haude M, Byrne R, Chung EH, Fauchier L, et al.; ESC Scientific Document Group. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace. 2019;21(2):192–3. doi:. http://dx.doi.org/10.1093/europace/euy174 PubMed

15 Gorenek B, Blomström Lundqvist C, Brugada Terradellas J, Camm AJ, Hindricks G, Huber K, et al.Cardiac arrhythmias in acute coronary syndromes: position paper from the joint EHRA, ACCA, and EAPCI task force. Europace. 2014;16(11):1655–73. doi:. http://dx.doi.org/10.1093/europace/euu208 PubMed

16 Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, et al.Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2015;17(10):1467–507. doi:. http://dx.doi.org/10.1093/europace/euv309 PubMed

17 Mehta SR, Bainey KR, Cantor WJ, Lordkipanidzé M, Marquis-Gravel G, Robinson SD, et al.; members of the Secondary Panel. 2018 Canadian Cardiovascular Society/Canadian Association of interventional Cardiology focused update of the guidelines for the use of antiplatelet therapy. Can J Cardiol. 2018;34(3):214–33. doi:. http://dx.doi.org/10.1016/j.cjca.2017.12.012 PubMed

18 Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al.; Writing Group on the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction; ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction. Eur Heart J. 2012;33(20):2551–67. doi:. http://dx.doi.org/10.1093/eurheartj/ehs184 PubMed

19 Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al.; ESC Committee for Practice Guidelines-CPG; Document Reviewers. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. Europace. 2012;14(10):1385–413. doi:. http://dx.doi.org/10.1093/europace/eus305 PubMed

20 Cutlip DE, Windecker S, Mehran R, Boam A, Cohen DJ, van Es GA, et al.; Academic Research Consortium. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007;115(17):2344–51. doi:. http://dx.doi.org/10.1161/CIRCULATIONAHA.106.685313 PubMed

21 Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, et al.Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011;123(23):2736–47. doi:. http://dx.doi.org/10.1161/CIRCULATIONAHA.110.009449 PubMed

22 McManus DD, Huang W, Domakonda KV, Ward J, Saczysnki JS, Gore JM, et al.Trends in atrial fibrillation in patients hospitalized with an acute coronary syndrome. Am J Med. 2012;125(11):1076–84. doi:. http://dx.doi.org/10.1016/j.amjmed.2012.05.024 PubMed

23 Lopes RD, Li L, Granger CB, Wang TY, Foody JM, Funk M, et al.Atrial fibrillation and acute myocardial infarction: antithrombotic therapy and outcomes. Am J Med. 2012;125(9):897–905. doi:. http://dx.doi.org/10.1016/j.amjmed.2012.04.006 PubMed

24 Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al.; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2016;37(38):2893–962. doi:. http://dx.doi.org/10.1093/eurheartj/ehw210 PubMed

25 Angeli F, Reboldi G, Garofoli M, Ramundo E, Poltronieri C, Mazzotta G, et al.Atrial fibrillation and mortality in patients with acute myocardial infarction: a systematic overview and meta-analysis. Curr Cardiol Rep. 2012;14(5):601–10. doi:. http://dx.doi.org/10.1007/s11886-012-0289-3 PubMed

26 Mehta RH, Dabbous OH, Granger CB, Kuznetsova P, Kline-Rogers EM, Anderson FA, et al.; GRACE Investigators. Comparison of outcomes of patients with acute coronary syndromes with and without atrial fibrillation. Am J Cardiol. 2003;92(9):1031–6. doi:. http://dx.doi.org/10.1016/j.amjcard.2003.06.001 PubMed

27 Poçi D, Hartford M, Karlsson T, Edvardsson N, Caidahl K. Effect of new versus known versus no atrial fibrillation on 30-day and 10-year mortality in patients with acute coronary syndrome. Am J Cardiol. 2012;110(2):217–21. doi:. http://dx.doi.org/10.1016/j.amjcard.2012.03.018 PubMed

28 Biasco L, Radovanovic D, Moccetti M, Rickli H, Roffi M, Eberli F, et al.New-onset or Pre-existing Atrial Fibrillation in Acute Coronary Syndromes: Two Distinct Phenomena With a Similar Prognosis. Rev Esp Cardiol (Engl Ed). 2019;72(5):383–91. doi:. http://dx.doi.org/10.1016/j.rec.2018.03.002 PubMed

29 Huang W, FitzGerald G, Goldberg RJ, Gore J, McManus RH, Awad H, et al.; TRACE-CORE Investigators. Performance of the GRACE risk score 2.0 simplified algorithm for predicting 1-year death following hospitalisation for an acute coronary syndrome in a contemporary multiracial cohort. Am J Cardiol. 2016;118(8):1105–10. doi:. http://dx.doi.org/10.1016/j.amjcard.2016.07.029 PubMed

30 Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, et al.Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med. 2016;375(25):2423–34. doi:. http://dx.doi.org/10.1056/NEJMoa1611594 PubMed

31 Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, et al.; RE-DUAL PCI Steering Committee and Investigators. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med. 2017;377(16):1513–24. doi:. http://dx.doi.org/10.1056/NEJMoa1708454 PubMed

32 Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R, et al.; AUGUSTUS Investigators. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med. 2019;380(16):1509–24. doi:. http://dx.doi.org/10.1056/NEJMoa1817083 PubMed

33 Vranckx P, Valgimigli M, Eckardt L, Tijssen J, Lewalter T, Gargiulo G, et al.Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet. 2019;394(10206):1335–43. doi:. http://dx.doi.org/10.1016/S0140-6736(19)31872-0 PubMed

34 Kozieł M, Potpara TS, Lip GYH. Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting. Res Pract Thromb Haemost. 2020;4(3):357–65. doi:. http://dx.doi.org/10.1002/rth2.12319 PubMed

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