Atrial fibrillation in acute coronary syndromes: Difference between revisions
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*Warfarin dose adjusted [[International Normalized Ratio]] ([[INR]]) between 2 and 2.5 | *Warfarin dose adjusted [[International Normalized Ratio]] ([[INR]]) between 2 and 2.5 | ||
*It is not unreasonable to use [[dabigatran]] in place of [[warfarin]] | *It is not unreasonable to use [[dabigatran]] in place of [[warfarin]] | ||
{| cellspacing="0" cellpadding="0" border="0" | |||
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| rowspan="6" | Atrial fibrillation and a coronary stent with moderate/high stroke risk (CHADS2 ≥ 1) | |||
| rowspan="2" | Low ST and low bleeding risk | |||
| BMS – triple Rx for at least 1 mo then OAC + single AP for 12 mo | |||
| rowspan="6" | After 12 mo | |||
OAC indefinitely | |||
|- | |||
| DES – triple therapy Rx for at least 6 mo then OAC + single AP for 12 mo | |||
|- | |||
| rowspan="2" | High ST and low bleeding risk | |||
| BMS – triple Rx for at 6 mo then OAC + single AP for 12 mo | |||
|- | |||
| DES - triple Rx for 12 mo | |||
|- | |||
| rowspan="2" | Any ST and high bleeding risk | |||
| BMS – triple Rx for at least 1 mo then OAC + single AP for 12 mo | |||
|- | |||
| DES – not recommended | |||
|} | |||
==References== | ==References== | ||
Revision as of 17:12, 2 September 2012
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
- 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
| Atrial fibrillation and a coronary stent with moderate/high stroke risk (CHADS2 ≥ 1) | Low ST and low bleeding risk | BMS – triple Rx for at least 1 mo then OAC + single AP for 12 mo | After 12 mo
OAC indefinitely |
| DES – triple therapy Rx for at least 6 mo then OAC + single AP for 12 mo | |||
| High ST and low bleeding risk | BMS – triple Rx for at 6 mo then OAC + single AP for 12 mo | ||
| DES - triple Rx for 12 mo | |||
| Any ST and high bleeding risk | BMS – triple Rx for at least 1 mo then OAC + single AP for 12 mo | ||
| DES – not recommended |