The Impact of AF on Natural History of CAD DR ALEXIA STAVRATI CARDIOLOGIST, DIRECTOR OF CARDIOLOGY DEPT, "G. PAPANIKOLAOU" GH, THESSALONIKI
CAD MOST COMMON CARDIOVASCULAR DISEASE MOST COMMON CAUSE OF DEATH (16,8%, 2013 VS 12% 1990) Lancet (2015) 9963, 117-71
CAD STEMI NSTE-ACS STABLE CAD ANGINA CABG PCI
MOST COMMON ARRHYTHMIA ATRIAL FIBRILLATION ONE IN FOUR MIDDLE-AGED ADULTS IN EUROPE AND THE US WILL DEVELOP AF AF PREVALENCE OF APPROXIMATELY 3% IN ADULTS AGED 20 YEARS OR OLDER, WITH GREATER PREVALENCE IN OLDER PERSONS (14% >80Y) European Heart Journal (2016) 37, 2893 2962
AF - PATTERNS PAROXYSMAL AF PERSISTENT AF LONG-STANDING PERSISTENT PERMANENT
AF AND CAD
AF AND CAD The prevalence of CAD in patients with AF ranges from 17% to 46,5% ROCKET-AF, RELY: CAD was present in 17% of the AF patients Kralev et al.(2011): 261 consecutive AF patients undergoing coronary angiography (without previously diagnosed or excluded CAD) showed that stable CAD was diagnosed in 13% of AF pts and in 21% of the pts PCI or CABG was performed, overall incidence of CAD was 34%. In older patients (>70y) the incidence of CAD was 41%.
AF AND CAD Lip et al.(1995): 46% των ασθενών με AF είχαν CAD Van Gelder et al. (2010) : σε 614 ασθενείς με μόνιμη AF το 18% είχαν CAD AFFIRM (2002): 38% ATHENA (2009): 30% 0,2-5% των ασθενών με CAD έχουν AF
AF AND CAD Use of antiarrhythmic drug therapy and clinical outcomes in older patients with concomitant atrial fibrillation and coronary artery disease Benjamin A. Steinberg et al, Europace, 2014 Apr AAD therapy and outcomes in 1738 older patients (age 65) with AF and CAD Concomitant atrial fibrillation (AF) and coronary artery disease (CAD) portend a poor prognosis yielding significant morbidity and mortality in older patients. At 5 years, rehospitalization exceeded 75% and mortality exceeded 33% Nearly one-third of patients with AF and CAD are treated with an antiarrhythmic drug (AAD), most commonly amiodarone.
AF AND STEMI
AF AND STEMI AF is the most frequent supraventricular arrhythmia AF, with up to 21% of STEMI patients affected Pre-existing, first-time detected, or of new onset AF
AF AND STEMI STEMI patients with documented AF have worse short- and long-term prognoses when compared with patients in sinus rhythm Presence of AF is associated with a higher reinfarction rate, higher stroke rate, higher risk for heart failure, and higher risk for sudden cardiac death Also transient, self-terminating AF during STEMI relates to a significantly higher stroke rate during long-term follow-up
Long term prognosis of atrial fibrillation in STelevation myocardial infarction patients undergoing percutaneous coronary intervention 1657 consecutive STEMI patients hospitalized in the cardiac intensive care unit during 2008-2014 NOAF was defined as AF occurring within 30days of the STEMI episode Patients were followed for a mean period of 3.4±2.1years 77 (4.6%) patients had paf and 47 (2.8%) had NOAF CONCLUSIONS: Prior AF and not new-onset AF is an independent predictor of both short and long term mortality in patients treated with PCI. Τopaz G et al, Int J Cardiol. 2017 Aug 1;240:228-233
Significance of Atrial Fibrillation Complicating ST- Segment Elevation Myocardial Infarction 4,363 consecutive STEMI patients treated invasively Finally, 4,099 subjects were included into further analysis, as 264 patients were excluded because of previous AF history New-onset AF was the independent predictor of death only in patients with anterior MI(hazard ratio 2.16) and this effect was stronger for late-onset AF (after 24H)(hazard ratio 2.86) In conclusion: The predictive value of new-onset AF was strongly related with STEMI location and timing of arrhythmia Podolecki T et al, Am J Cardiol. 2017 Aug 15;120(4):517-521
AF AND NSTE- ACS
AF AND NSTE-ACS Atrial fibrillation in its permanent or paroxysmal form is frequent in NSTE-ACS patients. The development of this arrhythmia occurs in 2 21% of patients with NSTE-ACS. Atrial fibrillation increases the risk of worsening ischemia, of developing heart failure and of thromboembolic complications. Atrial fibrillation complicating ACS is associated with increased in-hospital and long-term mortality. European Heart Journal doi:10.1093/eurheartj/ehv320
AF AND NSTE-ACS Thromboembolic MI in patients with AF Type 2 ΕΜ (NSTEMI)
AF AND NSTE - ACS GRACE (Global Registry of Acute Coronary Events): 21,785 patients with ACS, 1,700 (7.9%) had previous AF and 1,221 (6.2%) had new-onset AF Compared with patients with ACS without any AF, previous and new-onset AF are associated with increased hospital morbidity and mortality. Am J Cardiol. 2003 Nov 1;92(9):1031-6.
AF AND NSTE - ACS Increases in-hospital and long-term mortality irrespective of the time of occurrence. Relative mortality risk for patients with AF post MI is around 2.5 times that for patients without AF.
AF AND NSTE - ACS Depending on the duration of atrial fibrillation, heart rate, haemodynamics and functional status of the patient, different therapeutic actions are required, ranging from rate control to urgent electrical cardioversion
AF AND NSTE - ACS IC CAST N En J Med 1989 CAST Investigators
Recommendations for the management of patients with atrial fibrillation in the setting of non-stelevation acute coronary syndrome
Recommendations for the management of patients with atrial fibrillation in the setting of non-stelevation acute coronary syndrome
AF AND NSTE - ACS A particular diagnostic challenge results from the fact that patients with atrial fibrillation with rapid ventricular response may present with increased troponin levels as well as chest discomfort. In a large-scale atrial fibrillation trial, 9.2% of patients had elevated highsensitivity troponin I levels, and this proportion may be higher in the setting of acute-onset atrial fibrillation. Cardiac troponin dynamics in patients with atrial fibrillation and rapid ventricular rate may mimic type 1 MI. While in the presence of very high levels of troponin the likelihood of type 1 MI is high and coronary angiography is justified, in the majority of cases of atrial fibrillation and troponin elevation, ischemia detection should be considered first.
Recommendations for the management of patients with atrial fibrillation in the setting of non-stelevation acute coronary syndrome
Diagnostic accuracy of electrocardiographic STsegment depression in patients with rapid atrial fibrillation for the prediction of coronary artery disease 115 hemodynamically stable patients with AF, and a heart rate > 80% of their maximum predicted according to their age Group A included patients without any ST-segment abnormalities and group B patients with downward or horizontal ST-segment depression 1 mm in 2 or more contiguous leads. Prevalence of significant CAD among studied patients was 21.7%, 3/71 (4.2%) and 22/44 (50.0%) in group A and B, respectively In consecutive patients with rapid AF, the absence of ST-segment depression might indicate absence of CAD Tsigkas G et al, Can J Cardiol. 2014 Aug
AF AND STABLE CAD
Effect of atrial fibrillation on outcome in patients with known or suspected coronary artery disease referred for exercise stress testing 17,100 patients aged > or = 50 years with known or suspected CAD who underwent exercise electrocardiography (n = 11,911) or exercise echocardiography (n = 5,189) were evaluated. During a mean follow-up period of 6.5 + or - 3.9 years, 2,364 patients died, 1,311 had nonfatal myocardial infarctions, 1,615 underwent percutaneous coronary intervention, and 922 underwent coronary artery bypass surgery The 10-year mortality rate was 43% in patients with AF compared to 19% in those without AF (p <0.001). In multivariate analysis, AF remained an independent predictor of all-cause mortality (adjusted hazard ratio 1.45, 95% confidence interval 1.20 to 1.76, p <0.001), but not of nonfatal myocardial infarction or coronary revascularization. In conclusion AF was an independent predictor of all-cause mortality in patients with known or suspected CAD referred for exercise stress testing. Bouzas-Mosquera A et al, AM J Cardiol.2010 May 1;105(9):1207-11
Clinical characteristics and one year outcomes in Chinese atrial fibrillation patients with stable coronary artery disease: a population-based study A total of 1947 AF patients were analyzed, of whom 40.5% had stable CAD Stable CAD was independently associated with increased risk of 1- year all-cause mortality. One-year outcomes in patients with and without stable CAD Ying Bai et al, J Geriatr Cardiol.2016 Aug; 13(8): 665 671
AF AND CABG
AF AND CABG Νew-onset post-operative AF may occur in one-third of patients undergoing isolated CABG During 2nd-4th days after CABG The presence of post-operative AF after CABG is independently associated with increased cardiac morbidity and mortality, prolonged hospitalization, increased healthcare expenditure, and poor long-term prognosis European Heart Journal (2014) 35, 2541 2619
Bedside Tool for Predicting the Risk of Postoperative Atrial Fibrillation After Cardiac Surgery: The POAF Score Μariscalco G et al, JAHA 2014
AF AND CABG Β-Blockers - 33 studies - 4700 patients 16.3% vs 31.7% Arsenault KA et al, The Cochrane Library 2013
AF AND CABG Carvedilol vs Placebo
AF AND CABG Carvedilol vs Metoprolol Wang HS et al, PLOS One 2015
AF AND CABG AMIODARONE 5402 patients 19.4% vs 33% Arsenault KA et al, The Cochrane Library 2013
AF AND CABG COLCHICINE ν=1412 maybe useful for prevention of AF Lennertz C et al, Int J Cardiol 2017
AF AND PCI
AF AND PCI New-onset AF : change from sinus rhythm at admission to AF during/after PCI 2 6% of procedures and increases with age, pre-existing heart failure, acute myocardial infarction and arterial hypertension During the first 4 days after acute myocardial infarction Impaired prognosis, more than doubling the risk of death, congestive heart failure and stroke European Heart Journal (2014) 35, 2541 2619
AF AND PCI Oral anticoagulation in addition to antiplatelet therapy appears to decrease the risk of stroke after PCI European Heart Journal (2014) 35, 2541 2619
AF AND PCI 2,096 patients undergoing ppci. New-onset AF occurred in 6.2% of patients. New-onset AF after ppci is associated with adverse 30- day outcomes Mrdovic I et al, Coron Artery Dis 2012;23(1):1 8 3,307 consecutive patients with and without AF (sinus rhythm) undergoing PCI from January 2007 through December 2008 enrolled in a multicenter Australian registry. Periprocedural AF was present in 4.9%. Patients with periprocedural AF represent a very high-risk group with increased morbidity and mortality Chan W et al, Am J Cardiol 2012;109(4):471 477 6,308 consecutive patients undergoing PCI with DES between 2002 and 2009. AF was present in 5.3%. AF confers an increased risk of all-cause mortality, ischaemic stroke, and intracranial bleeding (4y ). Pilgrim Tet al, Euro Intervention 2013;8(9):1061 1071
ΣΤΕΦΑΝΙΟΓΡΑΦΙΚΑ ΕΥΡΗΜΑΤΑ ΣΕ AF
ΣΤΕΦΑΝΙΟΓΡΑΦΙΚΑ ΕΥΡΗΜΑΤΑ ΣΕ AFχεία AF It is often speculated that atrial ischemia plays an important pathophysiological role in the genesis of AF. Hence significant stenosis in the proximal RCA and the Cx prior to the take-off of the atrial branches should increase the likelihood of AF in these patients Retrospective analysis of 3220 patients: only 43% of patients with CAD and AF showed a diseased right artery and/or circumflex branch of the left coronary artery. Further, in only 65% of these patients was coronary stenosis localized before the take-off of atrial branches Lokshyn S et al. Atrial fibrillation in coronary artery disease. Int J Cardiol. 2000;72(2):133 6
ΣΤΕΦΑΝΙΟΓΡΑΦΙΚΑ ΕΥΡΗΜΑΤΑ ΣΕ AF 261 consecutive patients admitted to hospital with paroxysmal, persistent or permanent AF in this prospective study In patients with stable CAD no significant difference in the location of coronary artery stenosis among LAD, LCX and RCA was found. Srefan Kralev et al, PloS one 2011; 6(9): e24964
AF AND CAD Characteristics of coronary artery disease among patients with atrial fibrillation compared to patients with sinus rhythm Lukas J.et al, Hellenic Society of Cardiology (2017)
AF AND CAD In patients with stable CAD or MI undergoing coronary angiography, AF is not associated with the localization of coronary artery stenoses
CONCLUSIONS STEMI patients with documented AF have worse short- and long-term prognoses when compared with patients in sinus rhythm. Presence of AF is associated with a higher reinfarction rate, higher stroke rate, higher risk for heart failure, and higher risk for sudden cardiac death Also transient, self-terminating AF during STEMI relates to a significantly higher stroke rate during long-term follow-up Atrial fibrillation complicating ACS increases the risk of worsening ischemia, of developing heart failure and of thromboembolic complications and is associated with increased in-hospital and long-term mortality.
CONCLUSIONS The presence of post-operative AF after CABG is independently associated with increased cardiac morbidity and mortality, prolonged hospitalization, increased healthcare expenditure, and poor long-term prognosis Pre-operative anti-arrhythmic drug treatment may be initiated but will have to be weighed against side-effects. Beta-blockers significantly decrease the risk of AF after CABG. In patients with PCI AF confers an increased risk of all-cause mortality, ischemic stroke, intracranial bleeding and congestive heart failure.
The Impact of AF on Natural History of CAD DR ALEXIA STAVRATI CARDIOLOGIST, DIRECTOR OF CARDIOLOGY DEPT, "G. PAPANIKOLAOU" GH, THESSALONIKI