Impact of known or new-onset atrial fibrillation on 2-year cardiovascular event rate in patients with acute coronary syndromes: results from the prospective EPICOR Registry

Abstract

Background:

Atrial fibrillation (AF) is associated with increased morbidity in acute coronary syndrome patients, but impact on outcomes beyond 1 year is unclear.

Methods:

This was a post-hoc analysis from the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) registry (NCT01171404), a prospective, observational study conducted in Europe and Latin America, which enrolled acute coronary syndrome survivors at discharge. Antithrombotic management patterns, mortality, a composite endpoint of death/new non-fatal myocardial infarction/stroke and bleeding events were assessed after 2 years of follow-up in patients with or without AF.

Results:

Of 10,568 patients enrolled, 397 (4.7%) had prior AF and 382 (3.6%) new-onset AF during index hospitalisation. Fewer patients with AF underwent percutaneous coronary intervention (52.1% vs. 66.6%; P<0.0001). At discharge, fewer AF patients received dual antiplatelet therapy (71.6% vs. 89.5%; P<0.0001); oral anticoagulant use was higher in AF patients but was still infrequent (35.0% vs. 2.5%; P<0.0001). Use of dual antiplatelet therapy and oral anticoagulants declined over follow-up with over 50% of all AF/no AF patients remaining on dual antiplatelet therapy (55.6% vs. 60.6%), and 23.3% (new-onset AF) to 42.1% (prior AF) on oral anticoagulants at 2 years. At 2 years, mortality, composite endpoint and bleeding rates were higher in AF patients (all P<0.0001) compared to patients without AF. On multivariable analysis, the risk of mortality or the composite endpoint was significant for prior AF (P=0.003, P=0.001) but not new-onset AF (P=0.88, P=0.92).

Conclusions:

Acute coronary syndrome patients with AF represent a high-risk group with increased event rates during long-term follow-up. Prior AF is an independent predictor of mortality and/or ischaemic events at 2 years. Use of anticoagulants in AF after acute coronary syndrome is still suboptimal.

Keywords

Acute coronary syndromes antithrombotic therapy atrial fibrillation registry

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References

Chen

Crivera

Stokes

et al . Outcomes associated with comorbid atrial fibrillation and heart failure in Medicare beneficiaries with acute coronary syndrome. BMC Health Serv Res 2014; 14: 80.

Lopes

Pieper

Horton

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: 867–873.

Torres

Rocha

Marques

et al . Impact of atrial fibrillation in acute coronary syndromes. Rev Port Cardiol 2008; 27: 1407–1418.

Lau

Huynh

Chew

et al . Prognostic impact of types of atrial fibrillation in acute coronary syndromes. Am J Cardiol 2009; 104: 1317–1323.

Fuster

Ryden

Cannom

et al . ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114: e257–e354.

Kirchhof

Benussi

Kotecha

et al . 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 endorsed by the European Stroke Organisation (ESO). Europace 2016; 18: 1609–1678.

Steg

James

Atar

et al . ESC Gidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33: 2569–2619.

Lip

Windecker

Huber

et al . Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 2014; 35: 3155–3179.

Roffi

Patrono

Collet

et al . 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37: 267–315.

10.

Asencio

Huang

Alpert

JS.

Combining antiplatelet and antithrombotic therapy (triple therapy): what are the risks and benefits?

Am J Med 2014; 127: 579–585.

11.

Potpara

Lip

Dagres

et al . Management of acute coronary syndrome in patients with non-valvular atrial fibrillation: results of the European Heart Rhythm Association Survey. Europace 2014; 16: 293–298.

12.

Bueno

Danchin

Tafalla

et al . EPICOR (long-tErm follow-up of antithrombotic management Patterns In acute CORonary syndrome patients) study: rationale, design, and baseline characteristics. Am Heart J 2013; 165: 8–14.

13.

Bueno

Sinnaeve

Annemans

et al . Opportunities for improvement in anti-thrombotic therapy and other strategies for the management of acute coronary syndromes: Insights from EPICOR, an international study of current practice patterns. Eur Heart J Acute Cardiovasc Care 2016; 5: 3–12.

14.

Bueno

Pocock

Danchin

et al . International patterns of dual antiplatelet therapy duration after acute coronary syndromes. Heart 2017; 103: 132–138.

15.

Pocock

Bueno

Licour

et al . Predictors of one-year mortality at hospital discharge after acute coronary syndromes: a new risk score from the EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients) study. Eur Heart J Acute Cardiovasc Care 2014; 4: 509–517.

16.

Heidbuchel

Verhamme

Alings

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: 1467–1507.

17.

Gibson

Mehran

Bode

et al . An open-label, randomized, controlled, multicenter study exploring two treatment strategies of rivaroxaban and a dose-adjusted oral vitamin K antagonist treatment strategy in subjects with atrial fibrillation who undergo percutaneous coronary intervention (PIONEER AF-PCI). Am Heart J 2015; 169: 472–478.e475.

18.

Cannon

Bhatt

Oldgren

et al . Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 2017; 377: 1513–1524.

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