Atrial fibrillation in acute coronary syndromes
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Atrial fibrillation occurs in 1 to 20% of patients with acute coronary syndromes and is associated with a poorer prognosis.
Epidemiology and Demographics
Atrial fibrillation occurs in 1 to 20% (about 10%) of patients with acute coronary syndromes [1]
Risk Factors
Risk factors for the development of atrial fibrillation in the setting of ACS include:
- Female gender
- Older age
- Left ventricular dysfunction
Natural History, Complications, Prognosis
The occurrence of atrial fbrillation in the setting of acute coronary syndromes is associated with a poorer prognosis [2]:
- Any AF is associated with higher in hospital (OR 2.7), 30-day (OR 2.2), and 1-year mortality (OR 2.1) (p<0.001)
- New-onset AF was associated with higher in hospital (OR 5.2), 30-day (OR 3.9), and 1-year mortality (OR 3.1) (p<0.001)
Treatment
Current Practice Patterns Regarding the Patient with ACS and Atrial Fibrillation Among US Interventional Cardiologists in SCAI Survey
In general, most U.S. interventional cardiologists place a drug eluting stent and treat with "triple therapy" of ASA, clopidogrel and warfarin for 6 months after the procedure [3]:
1.How often do you use a drug eluting stent in patients with AF on warfarin?
- Never: 1.8%
- Rarely: 32.9%
- Sometimes: 35.3%
- Often: 30.6%
2. What is your preferred regimen in a patient with chronic AF on warfarin and requiring a DES?
- ASA, clopidogrel and warfarin for one month then ASA + warfarin: 5.3%
- ASA, clopidogrel and warfarin for one month then clopidogrel + warfarin: 19.3%
- ASA, clopidogrel and warfarin for 6 months or more: 47.5%
- ASA and clopidogrel for 6 months or more: 8.8%
- Clopidogrel and warfarin for 6 months or more: 9.6%
3. What is your preferred regimen in a patient with chronic AF on warfarin and requiring a BMS?
- ASA, clopidogrel and warfarin for one month then ASA + warfarin: 86.5%
- ASA, clopidogrel and warfarin for one month then clopidogrel + warfarin: 7.6%
- ASA, clopidogrel and warfarin for 6 months or more: 3.2%
- ASA and clopidogrel for 6 months or more: 1.3%
- Clopidogrel and warfarin for 6 months or more: 0.6%
General Guidelines in North America[4]
- Low dose aspirin (<100 mg per day)
- Clopidogrel is preferred in combination with aspirin and warfarin
- Prasugrel and ticagrelor cannot be recommended
- Warfarin dose adjusted International Normalized Ratio (INR) between 2 and 2.5
- It is not unreasonable to use dabigatran in place of warfarin
Specific Guidelines in North America[5]
Atrial fibrillation and a coronary stent with moderate/high stroke risk (CHADS2 ≥ 1)
Low Risk of Stent Thrombosis and Low Bleeding Risk
- BMS – ASA/Clopidogrel/oral anticoagulant for at least 1 mo then oral anticoagulant + single antiplatelet for 12 mo; oral anticoagulant indefinitely
- DES – ASA/Clopidogrel/oral anticoagulant for at least 6 mo then oral anticoagulant + single antiplatelet for 12 mo; oral anticoagulant indefinitely
High Risk of Stent Thrombosis and Low Bleeding Risk
- BMS – ASA/Clopidogrel/oral anticoagulant for at 6 mo then oral anticoagulant + single antiplatelet for 12 mo; oral anticoagulant indefinitely
- DES - ASA/Clopidogrel/oral anticoagulant for 12 mo; oral anticoagulant indefinitely
Any Risk of Stent Thrombosis and High Bleeding Risk
- BMS – ASA/Clopidogrel/oral anticoagulant for at least 1 mo then oral anticoagulant + single antiplatelet for 12 mo
- DES – Not recommended
Specific Guidelines in Europe [6]
Anticoagulation In PCI Patients At Low or Intermediate Hemorrhagic Risk
Elective Procedure with Bare-metal Stent
- 1 month: triple therapy of VKA (INR 2.0-2.5) + aspirin <= 100 mg/day + clopidogrel 75 mg/day
- Up to 12 months: combination of VKA (INR 2.0 -2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day)
- Lifelong: VKA (INR 2.0-3.0) alone
Elective Procedure with Drug-Eluting Stent
- 3 (-olimus group) to 6 (paclitaxel) months: triple therapy of VKA (INR 2.0 – 2.5) + aspirin <= 100 mg/day + clopidogrel 75 mg/day
- Up to 12 months: combination of VKA (INR 2.0 – 2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day)
- Lifelong: VKA (INR 2.0 – 3.0) alone
Procedure in the Setting of ACS with Bare-Metal or Drug-Eluting Stent
- 6 months: triple therapy of VKA (INR 2.0-2.5) + aspirin <= 100 mg/day + clopidogrel 75 mg/day
- Up to 12 months: combination of VKA (INR 2.0 -2.5) + clopidogrel 75 mg/day or aspirin 100 mg/day
- Lifelong: VKA (INR 2.0-3.0) alone
Anticoagulation In PCI Patients At High Hemorrhagic Risk
Elective Procedure with Bare-Metal Stent Placement
- 2- 4 weeks : triple therapy of VKA (INR 2.0 – 2.5) + aspirin <=100 mg/day + clopidogrel 75 mg/day
- Lifelong: VKA (INR 2.0 -3.0) alone
Procedure in the Setting of an Acute Coronary Syndrome with Bare-Metal Stent Placement
- 4 weeks: triple therapy of VKA (INR 2.0 – 2.5) + aspirin <=100 mg/day + clopidogrel 75 mg/day
- Up to 12 months: combination of VKA (INR – 2.0 – 2.5) + clopidogrel 75 mg/day ( or aspirin 100 mg/day)
- Lifelong: VKA (INR 2.0 – 3.0 alone)
References
- ↑ Schmitt J et al Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications. Eur Heart J 2009;30:1038–1045.
- ↑ Hersi et al. ANGIOLOGY August 2012 vol. 63 no. 6 466-471
- ↑ Faxon D, Thrombosis & Hemostasis 2011;106(3):522-34
- ↑ Faxon D, Thrombosis & Hemostasis 2011;106(3):522-34.
- ↑ Faxon D, Thrombosis & Hemostasis 2011;106(3):522-34.
- ↑ Thromb Haemost 2010;103:13–28