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Randomized Controlled Trial
. 2009 Aug;30(16):2019-28.
doi: 10.1093/eurheartj/ehp213. Epub 2009 Jun 6.

Antithrombotic therapy and outcomes of patients with atrial fibrillation following primary percutaneous coronary intervention: results from the APEX-AMI trial

Renato D Lopes  1 , Laine E Elliott, Harvey D White, Judith S Hochman, Frans Van de Werf, Diego Ardissino, Torsten T Nielsen, W Douglas Weaver, Petr Widimsky, Paul W Armstrong, Christopher B Granger
Affiliations
Randomized Controlled Trial

Antithrombotic therapy and outcomes of patients with atrial fibrillation following primary percutaneous coronary intervention: results from the APEX-AMI trial

Renato D Lopes et al. Eur Heart J. 2009 Aug.

Abstract

Aims: To assess the incidence and timing of atrial fibrillation (AF), describe antithrombotic therapy use, and evaluate the association of AF with 90 day mortality and other secondary clinical outcomes.

Methods and results: We studied 5745 ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention (PCI) in APEX-AMI. Approximately 11% had AF during hospitalization. Atrial fibrillation prevalence at baseline and at discharge was 4.8% [confidence interval (CI) 4.3-5.4%] and 2.5% (CI 2.1-2.9%), respectively. The proportion of 5466 patients without AF at baseline who developed new onset AF was 6.3% (CI 5.6-6.9%). This corresponded to 9.3 cases of new onset AF/1000 patient days at risk. New onset AF was independently associated with 90 day mortality [adjusted hazard ratio (HR) 1.81; 95% CI 1.06-3.09; P = 0.029] after accounting for baseline covariates and in-hospital procedures and complications. New onset AF was associated with shock (adjusted HR 3.81; 95% CI 1.88-7.70; P = 0.0002), congestive heart failure (adjusted HR 2.66; 95% CI 1.74-4.06; P < 0.0001), and stroke (adjusted HR 2.98; 95% CI 1.47-6.04; P = 0.0024) in models accounting for baseline covariates. Of AF patients, 55% did not receive oral anticoagulation therapy at discharge. Among patients with coronary stents, 5.1% were discharged on triple therapy. Patients at highest risk of stroke (CHADS(2) score > or =2) were least likely to receive oral anticoagulation at discharge (39%). Warfarin use in patients with AF at discharge (43.4%) was associated with lower rates of 90 day mortality and stroke.

Conclusion: Atrial fibrillation prevalence at baseline and at discharge was 4.8 and 2.5%, respectively. The proportion of patients who developed new onset AF was 6.3%. New onset AF was independently associated with 90 day mortality and was a marker of adverse outcomes in patients undergoing primary PCI.

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Figures

Figure 1
Figure 1
Timing of AF from randomization to discharge, including patients who died while hospitalized. New onset AF was defined as AF as a complication in the absence of AF at baseline. AF, atrial fibrillation; ST-segment elevation myocardial infarction, ST-segment elevation myocardial infarction.
Figure 2
Figure 2
Cumulative distribution of the time until development of new onset atrial fibrillation. Timing is described only for patients who developed new onset atrial fibrillation at some time during hospitalization.
Figure 3
Figure 3
Antithrombotic therapy in patients with atrial fibrillation (AF) at discharge according to CHADS2 score. (A) Percentage of patients with AF who received warfarin only, aspirin only, warfarin plus aspirin, aspirin plus clopidogrel, or triple therapy at discharge according to CHADS2 score. All medication categories are mutually exclusive. (B) Percentage of patients with AF who received any warfarin, any aspirin, or any clopidogrel at discharge according to CHADS2 score.
Figure 4
Figure 4
Landmark analysis: new onset atrial fibrillation is an independent predictor of 90 day mortality.
See this image and copyright information in PMC

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