Transcript AF in acute coronary syndrome

AF in acute coronary syndrome
Professor A. Al-Khadra
MBBS, FRCPC, FAHA
 Introduction
 Incidence
 Clinical variables associated with the
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development of atrial fibrillation
In-hospital mortality
Mortality during follow-up
Types of death
Impact of atrial fibrillation upon stroke
Anticoagulation
Treatment of atrial fibrillation in acute
myocardial infarction
Introduction
Introduction
 Most common sustained cardiac arrhythmia
 Increasing in prevalence with age
 Associated with increased long term risk of:
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Stroke and thromboembolism
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Congestive heart failure (CHF)
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All cause mortality
Introduction
 Atrial fibrillation can complicate acute
coronary syndromes particularly acute STsegment elevation myocardial infarction
 Associated rapid and irregular ventricular
rates during the arrhythmia may cause
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further impairment of the coronary circulation
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impairment of left ventricular function
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adverse consequences of neurohormonal
activation
Introduction
 Atrial fibrillation may also give rise to the
occurrence of severe ventricular
tachyarrhythmias perhaps due to:
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ischaemia,
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varying R–R intervals,
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or as a result of activation of the sympathetic
nervous system
Incidence
Incidence
 Treatment of AMI changed considerably over
the last 30 years
 Wide spread use of thrombolytic therapy
 Primary PCI becomes gold standard
treatment for AMI
 Early administration of beta blocker, ACE
inhibitors, ARBs and aldosterone antagonists
Incidence
 In the thrombolytic era, the incidence of AF in
patients admitted to hospital with AMI varied
between 6.8 and 21%
 GUSTO I trial which included 40 981 patients
with AMI, reported AF incidence of 10.4%
 Eldar et al. reported a 9.8% incidence of
paroxysmal AF in a consecutive series of
2866 patients
 GUSTO III study found an AF incidence of
6.8%
Incidence
 Between 1990 and 1997, the incidence of AF
complicating AMI decreased from 18% in
1990 to 11% in 1997, probably as a result of
improved therapy including more widespread use of thrombolysis
 OACIS study which included 2475 patients
treated with primary PCI, AF occurred in 12%
of patients
Incidence
 The Cooperative Cardiovascular Project
specifically looked at the incidence of AF in
elderly patients suffering from AMI
 106 780 patients over the age of 64 years
who were treated for AMI
 22.1% of these patients had AF with almost
half of the patients developing AF during
their hospital stay and the other half
presenting already with AF at admission
Incidence
 The use of ACE inhibitors and ARBs has
previously been found to be associated with
a reduction in AF in patients with different
cardiovascular diseases
 TRACE study 5.3% incidence of AF
 OPTIMAAL trial the incidence of AF was 2%
with a subsequent increase to 7.2% during
the follow-up period of 3 years
Incidence
 It is likely that the majority of these studies
underestimated the true AF incidence since
the diagnosis of AF was usually based on a
routine ECG
 CAPRICORN trial, the incidence of AF
complicating AMI could be reduced from 5.4
to 2.3% by administering the b-blocker
carvedilol
The RICO study
 No difference concerning the incidence of AF
between st elevation and non st elevation MI
patients (7.6 vs. 7.7%, P ¼ 0.334)
In summary
 AF complicating AMI incidence is between 2.3 and
21%.
 The wide-spread use of primary PCI, has been
associated with a notable decline in the AF incidence
 Trials evaluating the effects of ACE, ARBs, or bblockers on mortality and morbidity in patients with
AMI reported the lowest incidence rates of AF but the
major impact of this pharmacological therapy was
upon the late development of AF
 As our population ages, one can expect that AF will
remain a frequent and troublesome complication of
AMI
Clinical variables associated with
the development of atrial
fibrillation
Cooperative Cardiovascular Project
 Advanced heart failure on admission (Killip
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class IV) was the most significant predictor
Elevated admission heart rate
Advanced age
Similar findings were reported from the
GUSTO I
VALIANT study, received b-blockers and
thrombolytics less
Prospective Osaka Acute Coronary
Insufficiency Study
 Highest risk for AF development was an
admission heart rate ≥ 100/min
 Killip class IV
 Male gender
 Patient age
In summary
 Predictors of AF in the setting of AMI include:
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increased age
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presence of heart failure symptoms
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higher heart rates at admission
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left ventricular dysfunction
 These risk factors have been described
independently of the type of reperfusion
therapy (i.e. none, thrombolysis, PCI)
In-hospital mortality
GUSTO I trial
 Patients developing AF had:
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a significantly higher in-hospital mortality
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a higher incidence of re-infarction
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a higher incidence of cardiogenic shock
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a higher incidence of heart failure
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a higher incidence of asystole
 30 days mortality was higher for patients
developed AF after admission vs those
admitted with AF
Eldar et al. study
 Compared their data with patients treated in the
pre-thrombolytic era
 Patients with paroxysmal AF had a higher 30
day mortality
 Had relatively lower 30 day mortality rate when
they were treated in the thrombolytic era
Large database of elderly patients
 Development of AF during hospitalization
was associated with a higher mortality rate in
hospital and in the first 30 days
 In contrast, patients who were in AF at
admission had a similar mortality rate to that
of patients in sinus rhythm
Patients treated with PCI (Kinjo)
 More in-hospital events:
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cardiogenic shock,
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congestive heart failure,
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ventricular tachycardia, and ventricular fibrillation
 In hospital mortality rate was not significantly
increased
 Patient presented with AF or developed AF
during hospitalization appeared to have a
similar adverse impact upon outcomes
OPTIMAAL trial
 Patients with AF on admission had in-
hospital mortality similar to those with sinus
rhythm
 Patients who developed AF during
hospitalization had significantly higher
mortality
 All patients included in this study had left
ventricular dysfunction
TRACE study
 AF was primarily associated with increased
in-hospital mortality in heart failure patients
In summary
 Studies on in-hospital mortality strongly
suggest that the development of AF along
with an AMI is an independent predictor of all
cause mortality
Mortality during follow-up
GUSTO I
 1 year mortality in patients with AF was
higher than in those without the arrhythmia
Eldar/Sprint
 In contrast to the data on in-hospital mortality
there was no difference between patients
that presented with AF and those who
developed AF during hospitalization
 The comparison of 1 year mortality from
thrombolytic with pre-thrombolytic era
demonstrated a significant lower mortality in
the thrombolytic era
Rathore et al
 When patients were stratified according to
whether AF was present on admission or
developed during hospitalization, the 1 year
mortality in those presenting with AF was
lower in contrast to those who developed AF
after admission
Kinjo et al
 The 1 year mortality was significantly
increased in AMI patients treated by PCI who
developed AF after hospital admission
OPTIMAAL trial
 Had a long follow-up duration over 3 years
 Patients with AF at baseline had an
increased mortality risk compared with
individuals without the arrhythmia
 New-onset AF was associated with
increased subsequent 30 day mortality and
over the entire trial period
TRACE study
 Long term mortality was increased in all
subgroups except those with an LVEF < 0.25
 This is probably caused by the high mortality
rate of subsequent heart failure in any event
VALIANT study
 Three year mortality estimates were 20% in
patients without AF in the setting of AMI,
37% in those with AF complicating AMI, and
38% in patients with a history AF prior to the
AMI
In summary
 The bulk of evidence demonstrates that AF
in patients hospitalized for AMI has serious
adverse prognostic implications on long-term
mortality. This seems to apply for all patient
populations studied without significant
differences related to the treatment of AMI
Types of death
TRACE study
 Median follow-up period was 32 months
during which 34% patients died. In the AF
group, 50% died compared with 30% of
patients with sinus rhythm
 The authors concluded that the excess
mortality in AMI patients with AF is due to a
significant increase in sudden and nonsudden cardiac death
Impact of atrial fibrillation upon
stroke
Stroke in general population
 Patients with AF are at increased risk for
thrombo-embolic complications, particularly
for stroke
 Risk estimated by the CHADS2 score
Stroke after MI & AF
 Data on AF-associated stroke incidence in
the population of AMI patients is available
from only few investigations
 Significantly higher rate for in hospital stroke
was documented for patients with AF after
AMI by GUSTO I trial
 Majority of strokes were ischemic strokes
 3.1% of AMI patients with AF suffered from a
stroke compared with only 1.3% of patients
in sinus rhythm
Siu et al study
 At 1 year follow-up, the incidence of ischemic
stroke (10.2 vs. 1.8%) was substantially
higher in patients with transient AF compared
with those in sinus rhythm
 Of note, only anti-platelet agents were
prescribed in all patients and no oral
anticoagulation therapy was used.
In summary
 There are good data indicating that AF
complicating AMI not only increases the risk
for ischaemic stroke during hospitalization
but also during follow-up
 This seems to apply also for transient AF
which has reversed back to sinus rhythm at
the time of discharge
 These findings have implications for future
therapeutic recommendations
Anticoagulation
 Majority of trials discussed were conducted
before guide-lines on therapy of AF were
available
 Information on antithrombotic treatment of
patients with AF during AMI is very limited
and not based on controlled studies
Knowledge about Swedish Heart
Intensive care Admission
 Between 1995 and 2002
 Total of 6275 patients discharged alive after
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AMI and who had AF
29% were treated with OAC
60% were treated with ASA and/or
thienopyridines
11% did not receive any antithrombotic
therapy
In the OAC group, 26% received additional
antiplatelet therapy
Knowledge about Swedish Heart
Intensive care Admission
 All-cause mortality was significantly lower in
patients treated with OAC alone and was
also lower in those treated with OAC in
combination with antiplatelet therapy
compared with patients receiving only
ASA/thienopyridine.
Rubboliet al
 Treated 104 patients with AF and AMI with a
triple therapy of ASA, clopidogrel, and
warfarin after reperfusion therapy with PCI
and stenting
 No cardiac or peripheral thrombo-embolic
events were observed in 1 month follow-up
but (4.8%) periprocedural hemorrhages
occurred
 The overall bleeding rate in this small group
was 20% with triple therapy compared with
4.5% with dual antiplatelet therapy
Ruiz-Nodar et study
 Retrospective analysis on anticoagulation
treatment in patients with AF after coronary
artery stenting
 426 patients, 64%were treated for acute
coronary syndromes (including 20.1% AMI)
 213 received triple therapy with warfarin,
aspirin, and clopidogrel
Ruiz-Nodar et study
 Non-anticoagulation with warfarin was
associated with a significant increase in
major cardiovascular events (38.7 vs. 26.5%)
and all cause mortality (27.8 vs. 17.8%) at a
median follow-up of 594 days
Treatment of atrial fibrillation in
acute myocardial infarction
Atrial Fibrillation in
acute coronary syndromes
aClass
of recommendation. bLevel of evidence.
AF = atrial fibrillation, ACS = acute coronary syndrome; DCC = direct current cardioversion.
www.escardio.org/guidelines
European Heart Journal (2010) 31, 2369-2429
Summary
 AF occurs in 2–21% of patients with ACS
 Widespread use of PCI, during the acute
phase, has deceased the incidence of AF
 Similarly, the use of ACEIs, ARBs, or betablockers early after acute myocardial
infarction has reduced the incidence of AF
 AF is more commonly associated with ACS
in older patients and those with heart failure,
higher heart rates on admission, and LV
dysfunction
 AF complicating ACS is associated with
increased in-hospital and long-term mortality,
and increases the risk of ischemic stroke
during hospitalization and follow-up
 Recommendations for the management of
patients with AF in the setting of ACS are
based primarily on consensus, since
adequate trial data do not exist