Impact of periprocedural atrial fibrillation on short-term clinical outcomes following percutaneous coronary intervention

Atrial fibrillation incidence after coronary artery bypass graft surgery and percutaneous coronary intervention: the prospective AFAF cohort study

Objectives. Atrial fibrillation is a common arrhythmia in patients with ischemic heart disease. This study aimed to determine the cumulative incidence of new-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting surgery during 30 days of follow-up. Design. This was a prospective multi-center cohort study on atrial fibrillation incidence following percutaneous coronary intervention or coronary artery bypass grafting for stable angina or non-ST-elevation acute coronary syndrome. Heart rhythm was monitored for 30 days postoperatively by in-hospital telemetry and handheld thumb ECG recordings after discharge were performed. The primary endpoint was the cumulative incidence of atrial fibrillation 30 days after the index procedure. Results. In-hospital atrial fibrillation occurred in 60/123 (49%) coronary artery bypass graft and 0/123 percutaneous coronary intervention patients (p < .001). The cumulative incidence of atrial fibrillation after 30 days was 56% (69/123) of patients undergoing coronary artery bypass grafting and 2% (3/123) of patients undergoing percutaneous coronary intervention (p < .001). CABG was a strong predictor for atrial fibrillation compared to PCI (OR 80.2, 95% CI 18.1-354.9, p < .001). Thromboembolic stroke occurred in-hospital in one coronary artery bypass graft patient unrelated to atrial fibrillation, and at 30 days in two additional patients, one in each group. There was no mortality. Conclusion. New-onset atrial fibrillation during 30 days of follow-up was rare after percutaneous coronary intervention but common after coronary artery bypass grafting. A prolonged uninterrupted heart rhythm monitoring strategy identified additional patients in both groups with new-onset atrial fibrillation after discharge.

Adverse 30-Day Clinical Outcomes and Long-Term Mortality Among Patients With Preprocedural Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

OBJECTIVES

Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined.

METHODS

We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index.

RESULTS

13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9±10.9 vs 64.1±12.0 p<0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p<0.001), hypertension (74.4% vs 65.1% p<0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p<0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p<0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p<0.001). In-hospital major bleeding was more common in the AF group (3.1% vs 1.0% p<0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p<0.004) at a mean follow-up of 2.3±1.5 years.

CONCLUSIONS

Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.

Clinical Significance of Atrial Fibrillation Status in Patients With Percutaneous Coronary Intervention

Background

Patients undergoing percutaneous coronary intervention (PCI) often develop atrial fibrillation (AF). We investigated the clinical effects of AF status on in-hospital mortality and complications in patients with PCI using a recent large-scale nationwide dataset.

Methods

Using a claims-based dataset from 1022 hospitals in Japan for the time period between 2012 and 2016, patients with PCI were identified and classified into 3 groups according to AF status: no AF, prevalent AF before admission, and incident AF after admission. In-hospital mortality, complications, and medical costs were compared in crude and propensity-matched cohorts.

Results

In 659,525 hospitalized patients undergoing PCI, prevalent AF and incident AF were observed in 6.0% and 1.3% patients, respectively; the AF rates increased over 5 years. A greater proportion of older patients and patients with comorbidities had both of these categories of AF; undergoing PCI for acute coronary syndrome was common in incident AF. Both prevalent AF and incident AF were associated with worse crude outcomes and complications during hospitalization. In propensity-matched cohorts, incident AF was associated with a higher in-hospital mortality rate, longer length of stay, higher direct costs, and higher rate of complications, including stroke and acute kidney injury, compared with prevalent AF. These outcomes, except length of in-hospital stay, did not change for either AF status over 5 years.

Conclusions

Prevalent AF and incident AF in patients undergoing PCI were both associated with deteriorating crude outcomes and complications; in particular, incident AF was associated with worse adjusted outcomes and complications. Further efforts are needed to improve patient outcomes in an aging society in which the incidence of AF is increasing.

Relationship between predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score and mortality among patients with atrial fibrillation undergoing percutaneous coronary intervention

BACKGROUND

The predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy, PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy (DAPT) as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes, including mortality in patients with atrial fibrillation (AF) undergoing PCI is unknown.

OBJECTIVE

Role of P-DAPT score to study clinical outcomes, including mortality, hospitalization, and major bleeding, particularly among patients with AF.

METHODS

This is a retrospective observational study of 18,850 consecutive patients who underwent percutaneous coronary intervention (PCI) across a large multihospital healthcare system from 2010 to 2019. Patients were stratified into four groups depending on the presence or absence of AF and P-DAPT score, with score ≥ 25 defined as high risk. The primary outcome was all-cause mortality. The secondary outcomes evaluated were hospitalization and major bleeding.

RESULTS

In the unadjusted analyses, a P-DAPT score ≥ 25, in both AF and non-AF population, was associated with increased mortality, hospitalization, and bleeding. After adjusting for baseline covariates, no significant differences in major bleeding risk were found across the four groups. However, a P-DAPT score of ≥25 in AF patients was associated with a higher risk for hospitalizations related to cardiovascular causes (HR: 2.15 95% CI 2.00-2.3, p < .0001). Among AF patients, P-DAPT score ≥ 25 was found to be strongly associated with mortality (HR 3.5; 95% CI 2.95-4.25, p < .0001) as compared with AF patients with score < 25 (HR 1.18, 95% CI 0.88-1.54, p = .26).

CONCLUSION

In this large cohort of patients undergoing PCI, the P-DAPT score can help to identify patients at high risk for long-term mortality, particularly among those with atrial fibrillation.

Prediction of all-cause mortality in coronary artery disease patients with atrial fibrillation based on machine learning models

BACKGROUND

Machine learning (ML) can include more diverse and more complex variables to construct models. This study aimed to develop models based on ML methods to predict the all-cause mortality in coronary artery disease (CAD) patients with atrial fibrillation (AF).

METHODS

A total of 2037 CAD patients with AF were included in this study. Three ML methods were used, including the regularization logistic regression, random forest, and support vector machines. The fivefold cross-validation was used to evaluate model performance. The performance was quantified by calculating the area under the curve (AUC) with 95% confidence intervals (CI), sensitivity, specificity, and accuracy.

RESULTS

After univariate analysis, 24 variables with statistical differences were included into the models. The AUC of regularization logistic regression model, random forest model, and support vector machines model was 0.732 (95% CI 0.649-0.816), 0.728 (95% CI 0.642-0.813), and 0.712 (95% CI 0.630-0.794), respectively. The regularization logistic regression model presented the highest AUC value (0.732 vs 0.728 vs 0.712), specificity (0.699 vs 0.663 vs 0.668), and accuracy (0.936 vs 0.935 vs 0.935) among the three models. However, no statistical differences were observed in the receiver operating characteristic (ROC) curve of the three models (all P > 0.05).

CONCLUSION

Combining the performance of all aspects of the models, the regularization logistic regression model was recommended to be used in clinical practice.

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.

In-hospital Bleeding Outcomes of Oral Anticoagulant and Dual Antiplatelet Therapy During Percutaneous Coronary Intervention: An Analysis From the Japanese Nationwide Registry

Supplemental Digital Content is Available in the Text.

The type of periprocedural antithrombotic regimen that is the safest and most effective in percutaneous coronary intervention (PCI) patients on oral anticoagulant (OAC) therapy has not been fully investigated. We aimed to retrospectively investigate the in-hospital bleeding outcomes of patients receiving OAC and antiplatelet therapies during PCI using Japanese nationwide multicenter registry data. A total of 26,938 patients who underwent PCI with OAC and antiplatelet therapies between 2016 and 2017 were included. We investigated in-hospital bleeding requiring blood transfusion, mortality, and stent thrombosis according to the antithrombotic regimens used at the time of PCI: OAC + single antiplatelet therapy (double therapy) and OAC + dual antiplatelet therapy (triple therapy). The antiplatelet agents included aspirin, clopidogrel, and prasugrel. The OAC agents included warfarin and direct OACs. Adjusting the dose of OAC or intermitting OAC before PCI was at each operator's discretion. In the study population [mean age (SD), 73.5 (9.5) years; women, 21.5%], the double therapy and triple therapy groups comprised 5546 (20.6%) and 21,392 (79.4%) patients, respectively. Bleeding requiring transfusion was not significantly different between the groups [adjusted odds ratio (aOR), 0.700; 95% confidence interval (CI), 0.420–1.160; P = 0.165] (triple therapy as a reference). Mortality was not significantly different (aOR, 1.370; 95% CI, 0.790–2.360; P = 0.258). Stent thrombosis was significantly different between the groups (aOR, 3.310; 95% CI, 1.040–10.500; P = 0.042) (triple therapy as a reference). In conclusion, for patients on OAC therapy who underwent PCI, periprocedural triple therapy may be safe with respect to in-hospital bleeding risks. However, further investigations are warranted to establish the safety and efficacy of periprocedural triple therapy.

Effect of Age on Clinical Outcomes in Elderly Patients (>80 Years) Undergoing Percutaneous Coronary Intervention: Insights From a Multi-Centre Australian PCI Registry

OBJECTIVES

To evaluate the effect of age in an all-comers population undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Age is an important consideration in determining appropriateness for invasive cardiac assessment and perceived clinical outcomes.

METHODS

We analysed data from 29,012 consecutive patients undergoing PCI in the Melbourne Interventional Group (MIG) registry between 2005 and 2017. 25,730 patients <80 year old (78% male, mean age 62±10 years; non-elderly cohort) were compared to 3,282 patients ≥80 year old (61% male, mean age 84±3 years; elderly cohort).

RESULTS

The elderly cohort had greater prevalence of hypertension, diabetes and previous myocardial infarction (all p<0.001). Elderly patients were more likely to present with acute coronary syndromes, left ventricular ejection fraction <45% and chronic kidney disease (p<0.0001). In-hospital, 30-day and long-term all-cause mortality (over a median of 3.6 and 5.1 years for elderly and non-elderly cohorts, respectively) were higher in the elderly cohort (5.2% vs. 1.9%; 6.4% vs. 2.2%; and 43% vs. 14% respectively, all p<0.0001). In multivariate Cox regression analysis, estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m² (HR 3.8, 95% CI: 3.4-4.3), cardiogenic shock (HR 3.0, 95% CI: 2.6-3.4), ejection fraction <30% (HR 2.5, 95% CI: 2.1-2.9); and age ≥80 years (HR 2.8, 95% CI: 2.6-3.1) were independent predictors of long-term all-cause mortality (all p<0.0001).

CONCLUSION

The elderly cohort is a high-risk group of patients with increasing age being associated with poorer long-term mortality. Age, thus, should be an important consideration when individualising treatment in elderly patients.

Percutaneous Ventricular Assist Device vs. Intra-Aortic Balloon Pump for Hemodynamic Support in Acute Myocardial Infarction-Related Cardiogenic Shock and Coexistent Atrial Fibrillation: A Nationwide Propensity-Matched Analysis'

BACKGROUND

Patients suffering an acute myocardial infarction complicated by cardiogenic shock (AMICS) may experience clinical deterioration with concomitant atrial fibrillation (AF). Recent data suggest that percutaneous ventricular assist devices (pVADs) provide superior hemodynamic support over intra-aortic balloon pump (IABP) in AMICS. In patients with AF+AMICS, however, outcomes data comparing these two devices remain limited.

METHODS

Using the National Inpatient Sample datasets (2008-2014) and a propensity-score matched analysis, we compared the outcomes of AMICS+AF hospitalized patients undergoing PCI with pVAD vs. IABP support.

RESULTS

A total of 12,842 AMICS+AF patients were identified (pVAD=468, IABP=12,374). The matched groups (pVAD=443, IABP=443) were comparable in terms of mean age (70.3 ± 12.0 vs. 70.4 ± 11.0yrs, p = 0.92). The utilization of pVAD was higher in whites but lower in Medicare/Medicaid beneficiaries as compared to IABP. The pVAD group demonstrated higher rates of obesity (13.6% vs. 7.8%, p = 0.006) and dyslipidemia (48.4% vs. 41.8%, p = 0.05). There was no difference in the in-hospital mortality (40.5% vs. 36.8%, p = 0.25); however, pVAD group had a lower incidence of post-procedural MI and higher incidences of stroke (7.8% vs. 4.4%, p = 0.03), hemorrhage (5.6% vs. 2.3%, p = 0.01), discharges to home health care (13.5% vs. 10.1%, p<0.001) and to other facilities (29.1% vs. 24.9%, p<0.001) as compared to IABP group. There was no difference between the groups in terms of mean length of stay or hospital charges.

CONCLUSIONS

All-cause inpatient mortality was similar in AMICS+AF patients undergoing PCI who were treated with either pVAD or IABP. The pVAD group, however, experienced more complications while consuming greater healthcare resources.

Bleeding Severity in Percutaneous Coronary Intervention (PCI) and Its Impact on Short-Term Clinical Outcomes

Bleeding severity in patients undergoing percutaneous coronary intervention (PCI), defined by the Bleeding Academic Research Consortium (BARC), portends adverse prognosis. We analysed data from 37,866 Australian patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR), and investigated the association between increasing BARC severity and in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) (a composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, or stroke). Independent predictors associated with major bleeding (BARC groups 3&5), and MACCE were also assessed. There was a stepwise increase in in-hospital and 30-day MACCE with greater severity of bleeding. Independent predictors of bleeding included female sex (Odds Ratio (OR) 1.34), age (OR 1.02), fibrinolytic therapy (OR 1.77), femoral access (OR 1.51), and ticagrelor (OR 1.42), all significant at the p < 0.001 level. Following adjustment of clinically important variables, BARC 3&5 bleeds (OR 4.37) were still predictive of cumulative in-hospital and 30-day MACCE. In conclusion, major bleeding is an uncommon but potentially fatal PCI complication and was independently associated with greater MACCE rates. Efforts to mitigate the occurrence of bleeding, including radial access and judicious use of potent antiplatelet therapies, may ameliorate the risk of short-term adverse clinical outcomes.

Temporal trends in prevalence and outcomes of atrial fibrillation in patients undergoing percutaneous coronary intervention

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia in patients undergoing percutaneous coronary intervention (PCI).

HYPOTHESIS

Large administrative data may provide further insight into temporal trends in the prevalence and burden of AF in patients who underwent PCI.

METHODS

Using the National Inpatient Sample database in the U.S., AF patients ≥18 years who underwent PCI between 2005 and 2014 and were identified by the International Classification of Diseases, ninth revision, Clinical Modification, were examined. In-hospital mortality, morbidity, resource use, and medical costs were evaluated in crude and propensity-matched analyses.

RESULTS

Among an estimated 6 272 232 hospitalizations, of patients undergoing PCI, AF prevalence was 9.9% and steadily increased from 8.6% to 12.0% between 2005 and 2014 (P < .001); there was also a greater proportion of comorbidities. There was a marked increase in AF prevalence among those aged ≥65 years and those undergoing elective PCIs. AF was independently associated with higher in-hospital mortality and higher rates of transient ischaemic attack/stroke, bleeding complications, and non-home discharge. Excessive in-hospital mortality, stroke rate, gastrointestinal bleeding, blood transfusion, length of stay, and costs among AF hospitalizations were consistently observed throughout the study period.

CONCLUSION

AF becomes more prevalent in patients undergoing PCI, possibly due to a higher comorbidity, particularly in elderly patients with non-acute indications. Less favorable trends in mortality, bleeding, and stroke among AF patients who underwent PCI were consistent over time. Continuous efforts are needed to improve outcomes and manage strategies for AF patients undergoing PCI.

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.

Risk of new-onset atrial fibrillation after drug-eluting stent implantation in patients with stable coronary artery disease

BACKGROUND

New-onset atrial fibrillation (NOAF) is associated with adverse outcomes in patients with coronary artery disease (CAD). Although newer generation drug-eluting stents (NG-DESs) are more beneficial than bare-metal stents (BMSs) in reducing the risk of in-stent restenosis and revascularization, whether NG-DES implantation in patients with stable CAD reduces NOAF risk compared with BMS implantation remains unknown.

METHODS

This population-based cohort study was conducted using data from Taiwan's National Health Insurance Research Database. Propensity score matching was used to select 18,423 pairs of patients with stable CAD receiving NG-DES implantation and BMS implantation with similar baseline characteristics for evaluation. A competing risk model was used to evaluate the risk of NOAF between the NG-DES and BMS groups in which death was considered a competing risk.

RESULTS

After adjustment for patients' clinical variables, the use of NG-DESs was associated with a decreased risk of NOAF at 1-year follow-up (adjusted subdistribution hazard ratio [SHR] = 0.79, 95% confidence interval [CI] = 0.68-0.93, P = 0.005) compared with the use of BMSs. Similar results indicated that NG-DESs were beneficial for reducing the risk of NOAF (adjusted SHR = 0.81, 95% CI = 0.67-0.97, P = 0.020) in patients with a CHA₂DS₂-VASc score of ≥2. These findings were also consistent with those for patients who received dual antiplatelet therapy for an undefined duration of >1 month following stent implantation.

CONCLUSIONS

Our findings suggest that NG-DESs might reduce the risk of NOAF in patients with stable CAD.

New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease: The EXCEL Trial

BACKGROUND

There is limited information on the incidence and prognostic impact of new-onset atrial fibrillation (NOAF) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD).

OBJECTIVES

This study sought to determine the incidence of NOAF following PCI and CABG for LMCAD and its effect on 3-year cardiovascular outcomes.

METHODS

In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. Outcomes were analyzed according to the development of NOAF during the initial hospitalization following revascularization.

RESULTS

Among 1,812 patients without atrial fibrillation on presentation, NOAF developed at a mean of 2.7 ± 2.5 days after revascularization in 162 patients (8.9%), including 161 of 893 (18.0%) CABG-treated patients and 1 of 919 (0.1%) PCI-treated patients (p < 0.0001). Older age, greater body mass index, and reduced left ventricular ejection fraction were independent predictors of NOAF in patients undergoing CABG. Patients with versus without NOAF had a significantly longer duration of hospitalization, were more likely to be discharged on anticoagulant therapy, and had an increased 30-day rate of Thrombolysis In Myocardial Infarction major or minor bleeding (14.2% vs. 5.5%; p < 0.0001). By multivariable analysis, NOAF after CABG was an independent predictor of 3-year stroke (6.6% vs. 2.4%; adjusted hazard ratio [HR]: 4.19; 95% confidence interval [CI]: 1.74 to 10.11; p = 0.001), death (11.4% vs. 4.3%; adjusted HR: 3.02; 95% CI: 1.60 to 5.70; p = 0.0006), and the primary composite endpoint of death, MI, or stroke (22.6% vs. 12.8%; adjusted HR: 2.13; 95% CI: 1.39 to 3.25; p = 0.0004).

CONCLUSIONS

In patients with LMCAD undergoing revascularization in the EXCEL trial, NOAF was common after CABG but extremely rare after PCI. The development of NOAF was strongly associated with subsequent death and stroke in CABG-treated patients. Further studies are warranted to determine whether prophylactic strategies to prevent or treat atrial fibrillation may improve prognosis in patients with LMCAD who are undergoing CABG. (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776).

Heart Rate as a Predictor of Outcome Following Percutaneous Coronary Intervention

Data from previous studies of patients with heart failure and coronary artery disease suggest that those with higher resting heart rates (HRs) have worse cardiovascular outcomes. We sought to evaluate whether HR immediately before percutaneous coronary intervention (PCI) is an independent predictor for 30-day outcome. We analyzed the outcome of 3,720 patients who had HR recorded before PCI from the Melbourne Interventional Group registry. HR and outcomes were analyzed by quintiles, and secondarily by dichotomizing into <70 or ≥70 beats/min. Patients with cardiogenic shock, intra-aortic balloon pump or inotropic support, and out-of-hospital arrest were excluded. The mean ± SD HR was 70.9 ± 14.7 beats/min. HR by quintile was 55 ± 5, 64 ± 2, 70 ± 1, 77 ± 3, and 93 ± 13 beats/min, respectively. Patients with higher HR were more likely to be women, current smokers, have higher systolic and diastolic blood pressure, atrial fibrillation, recent heart failure, lower ejection fraction, and ST-elevation myocardial infarction as the indication for the PCI (all p ≤0.002). However, rates of treated hypertension, multivessel disease, previous myocardial infarction, PCI, and coronary bypass surgery were lower (all p ≤0.004). Increased HR was associated with higher 30-day mortality (p for trend = 0.04), target vessel revascularization (p for trend = 0.003), and 30-day major adverse cardiac events (MACE) (p for trend = 0.004). In a multivariable analysis, HR was an independent predictor of 30-day MACE (OR 1.21 per quintile; 95% confidence interval (CI): 1.06 to 1.39, p = 0.004). When dichotomized into <70 or ≥70 beats/min, HR independently predicted both 30-day MACE (OR 1.59, 95% CI 1.08 to 2.36, p = 0.02) and 30-day mortality (OR 2.80, 95% CI 1.10 to 7.08, p = 0.03). In conclusion, HR immediately before PCI is an independent predictor of adverse 30-day cardiovascular outcomes.

Outcomes of patients with periprocedural atrial fibrillation undergoing percutaneous coronary intervention for chronic total occlusion

BACKGROUND

Successful CTO recanalization has been associated with clinical benefit. Outcomes of patients with atrial fibrillation undergoing CTO PCI have not been investigated, yet.

AIMS

This study sought to evaluate the association between atrial fibrillation and outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO).

METHODS

Consecutive patients undergoing CTO PCI between January 2005 and December 2013 were divided into patients with and without atrial fibrillation, and propensity-matched models used to adjust for baseline differences between groups. The primary outcome was all-cause mortality at a median follow-up of 3.2 (interquartile range 3.1-4.5) years.

RESULTS

Of 2002 patients undergoing CTO PCI, atrial fibrillation was present in 169 (8.4%) patients. Patients with atrial fibrillation were older, and more frequently had hypertension, left ventricular systolic dysfunction, and chronic kidney disease. Before matching, all-cause mortality was 39.6 and 14.5% in the atrial fibrillation and the sinus rhythm groups (HR 2.92, 95% CI 2.23-3.82, p < 0.001). In the propensity-matched model, atrial fibrillation remained associated with an increased risk of mortality (HR 1.62, 95% CI 1.06-2.47, p = 0.03). In the unmatched patient cohort, all-cause mortality was significantly reduced in patients with procedural success, both in the atrial fibrillation (34.9 versus 55.0%, adjusted HR 0.99, 95% CI 0.97-1.00, p = 0.02) and the sinus rhythm groups (12.8 versus 23.0%, adjusted HR 0.70, 95% CI 0.53-0.92, p = 0.01).

CONCLUSIONS

Although atrial fibrillation is independently associated with mortality after CTO PCI, substantial survival benefit of successful CTO recanalization is observed in both patients with and without atrial fibrillation.

Outcomes of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

BACKGROUND

Atrial fibrillation (AF) is increasing in prevalence, and patients with a history of AF commonly undergo percutaneous coronary intervention (PCI). There is a paucity of contemporary data on the association between AF and clinical outcomes after PCI.

OBJECTIVES

The study sought to evaluate the association between AF and in-hospital adverse outcomes using a large, prospective multicenter registry.

METHODS

Data for consecutive PCI cases from 47 hospitals performed between April 2011 and December 2014 were utilized for the analysis. Propensity-matched multivariate analysis was used to adjust for differences in baseline characteristics between patients with and without a history of AF.

RESULTS

Of 113,283 PCI cases during the study period, a history of AF was present in 13,912 patients (12%), which varied by institution (range 2.5% to 18.4%). At baseline, patients with a history of AF were older and were more likely to have comorbid congestive heart failure, cardiomyopathy, cerebrovascular disease, and chronic lung disease. Patients with a history of AF were more likely to have in-hospital complications, including in-hospital mortality (3% vs. 1%). In propensity-matched analysis, patients with a history of AF were more likely to be treated with a bare-metal stent (27% vs. 18%). In the propensity-matched model, AF remained independently associated with an increased risk of developing post-procedural bleeding (odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.15 to 1.52), heart failure (OR: 1.33; 95% CI: 1.17 to 1.52), cardiogenic shock (OR: 1.26; 95% CI: 1.08 to 1.48), and in-hospital mortality (OR: 1.41; 95% CI: 1.18 to 1.68).

CONCLUSIONS

AF is common among patients undergoing PCI. AF is associated with older age, the presence of other comorbidities, and independently associated with in-hospital post-procedural heart failure, cardiogenic shock, and mortality.

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.

Impact of Triple Therapy in Elderly Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Background and Purpose

Selecting an ideal antithrombotic therapy for elderly patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) can be challenging since they have a higher thromboembolic and bleeding risk than younger patients. The current study aimed to assess the efficacy and safety of triple therapy (TT: oral anticoagulation plus dual antiplatelet therapy: aspirin plus clopidogrel) in patients ≥75 years of age with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).

Methods

A prospective multicenter study was conducted from 2003 to 2012 at 6 Spanish teaching hospitals. A cohort study of consecutive patients with AF undergoing PCI and treated with TT or dual antiplatelet therapy (DAPT) was analyzed. All outcomes were evaluated at 1-year of follow-up.

Results

Five hundred and eighty-five patients, 289 (49%) of whom were ≥75 years of age (79.6±3.4 years; 33% women) were identified. TT was prescribed in 55.9% of patients at discharge who had a higher thromboembolic risk (CHA₂DS₂VASc score: 4.23±1.51 vs 3.76±1.40, p = 0.007 and a higher bleeding risk (HAS-BLED ≥3: 88.6% vs 79.2%, p = 0.02) than those on DAPT. Therefore, patients on TT had a lower rate of thromboembolism than those on DAPT (0.6% vs 6.9%, p = 0.004; HR 0.08, 95% CI: 0.01–0.70, p = 0.004). Major bleeding events occurred more frequently in patients on TT than in those on DAPT (11.7% vs 2.4%, p = 0.002; HR 5.2, 95% CI: 1.53–17.57, p = 0.008). The overall mortality rate was similar in both treatment groups (11.9% vs 13.9%, p = 0.38); however, after adjustment for confounding variables, TT was associated with a reduced mortality rate (HR 0.33, 95% CI: 0.12–0.86, p = 0.02).

Conclusions

In elderly patients with AF undergoing PCI, the use of TT compared to DAPT was associated with reduced thromboembolism and mortality rates, although a higher rate of major bleeding.

Dual antiplatelet therapy versus oral anticoagulation plus dual antiplatelet therapy in patients with atrial fibrillation and low-to-moderate thromboembolic risk undergoing coronary stenting: design of the MUSICA-2 randomized trial

BACKGROUND

Oral anticoagulation (OAC) is the recommended therapy for patients with atrial fibrillation (AF) because it reduces the risk of stroke and other thromboembolic events. Dual antiplatelet therapy (DAPT) is required after percutaneous coronary intervention and stenting (PCI-S). In patients with AF requiring PCI-S, the association of DAPT and OAC carries an increased risk of bleeding, whereas OAC therapy or DAPT alone may not protect against the risk of developing new ischemic or thromboembolic events.

OBJECTIVE

The MUSICA-2 study will test the hypothesis that DAPT compared with triple therapy (TT) in patients with nonvalvular AF at low-to-moderate risk of stroke (CHADS2 score ≤2) after PCI-S reduces the risk of bleeding and is not inferior to TT for preventing thromboembolic complications.

DESIGN

The MUSICA-2 is a multicenter, open-label randomized trial that will compare TT with DAPT in patients with AF and CHADS2 score ≤2 undergoing PCI-S. The primary end point is the incidence of stroke or any systemic embolism or major adverse cardiac events: death, myocardial infarction, stent thrombosis, or target vessel revascularization at 1 year of PCI-S. The secondary end point is the combination of any cardiovascular event with major or minor bleeding at 1 year of PCI-S. The calculated sample size is 304 patients.

CONCLUSIONS

The MUSICA-2 will attempt to determine the most effective and safe treatment in patients with nonvalvular AF and CHADS2 score ≤2 after PCI-S. Restricting TT for AF patients at high risk for stroke may reduce the incidence of bleeding without increasing the risk of thromboembolic complications.

Calcium signalling microdomains and the t-tubular system in atrial mycoytes: potential roles in cardiac disease and arrhythmias

The atria contribute 25% to ventricular stroke volume and are the site of the commonest cardiac arrhythmia, atrial fibrillation (AF). The initiation of contraction in the atria is similar to that in the ventricle involving a systolic rise of intracellular Ca(2+) concentration ([Ca(2+)](i)). There are, however, substantial inter-species differences in the way systolic Ca(2+) is regulated in atrial cells. These differences are a consequence of a well-developed and functionally relevant transverse (t)-tubule network in the atria of large mammals, including humans, and its virtual absence in smaller laboratory species such as the rat. Where T-tubules are absent, the systolic Ca(2+) transient results from a 'fire-diffuse-fire' sequential recruitment of Ca(2+) release sites from the cell edge to the centre and hence marked spatiotemporal heterogeneity of systolic Ca(2+). Conversely, the well-developed T-tubule network in large mammals ensures a near synchronous rise of [Ca(2+)](i). In addition to synchronizing the systolic rise of [Ca(2+)](i), the presence of T-tubules in the atria of large mammals, by virtue of localization of the L-type Ca(2+) channels and Na(+)-Ca(2+) exchanger antiporters on the T-tubules, may serve to, respectively, accelerate changes in the amplitude of the systolic Ca(2+) transient during inotropic manoeuvres and lower diastolic [Ca(2+)](i). On the other hand, the presence of T-tubules and hence wider cellular distribution of the Na(+)-Ca(2+) exchanger may predispose the atria of large mammals to Ca(2+)-dependent delayed afterdepolarizations (DADs); this may be a determining factor in why the atria of large mammals spontaneously develop and maintain AF.

Prognosis of patients with atrial fibrillation undergoing percutaneous coronary intervention receiving drug eluting stents

BACKGROUND

Atrial fibrillation (AF) is increasingly prevalent in elderly patients and adversely affects clinical outcomes after coronary artery bypass grafting, non-cardiac surgery or myocardial infarction. Aim of the present analysis was to investigate the prognostic impact of AF in patients undergoing drug eluting stent (DES) implantation during a 1-year follow-up.

PATIENTS AND METHODS

5,772 consecutive patients undergoing percutaneous coronary intervention were enrolled into the German Drug Eluting Stent Registry (DES.DE) and were followed for 12 months. Of these 455 had AF and 5,317 in sinus rhythm served as controls. Univariate and multivariate logistic regression analyses were used to determine the risk of major adverse cardiac and cerebrovascular events (MACCE) and bleeding complications.

RESULTS

Patients with AF were older (71.3 ± 7.6 vs. 64.7 ± 10.5 years) and had a higher prevalence of diabetes, hypertension, renal insufficiency as well as more prior bypass surgery, stroke and peripheral arterial disease. Cardiogenic shock (2.9 vs. 1.4 %; p < 0.05), left ventricular ejection fraction ≤40 % (21.0 vs. 11.4 %; p < 0.0001) and triple vessel disease (44.4 vs. 37.9 %; p < 0.01) were more frequent in patients with AF than in controls. MACCE (OR 2.08, 95 % CI 1.56-2.77), total mortality (OR 3.27, 95 % CI 2.32-4.62) and non-fatal stroke (OR 2.03, 95 % CI 1.03-4.00) as well as bleeding complications (OR 1.88, 95 % CI 1.13-3.12) during the 1-year follow-up were more frequent in patients with AF (univariate analysis). In multivariate analyses adjusting for covariates determined to be relevant at baseline, the risk for total mortality remained elevated (OR 1.63, 95 % CI 1.05-2.52).

CONCLUSIONS

AF is an important predictor of long-term mortality in patients undergoing DES implantation.