Atrial fibrillation in acute coronary syndromes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview[edit | edit source]

Atrial fibrillation occurs in 1 to 20% of patients with acute coronary syndromes and is associated with a poorer prognosis.

Epidemiology and Demographics[edit | edit source]

Atrial fibrillation occurs in 1 to 20% (about 10%) of patients with acute coronary syndromes ^[1]

Risk Factors[edit | edit source]

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[edit | edit source]

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[edit | edit source]

Current Practice Patterns Regarding the Patient with ACS and Atrial Fibrillation Among US Interventional Cardiologists in SCAI Survey[edit | edit source]

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][edit | edit source]

• 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][edit | edit source]

Atrial fibrillation and a coronary stent with moderate/high stroke risk (CHADS2 ≥ 1)[edit | edit source]

Low Risk of Stent Thrombosis and Low Bleeding Risk[edit | edit source]

• 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[edit | edit source]

• 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[edit | edit source]

• 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][edit | edit source]

Anticoagulation In PCI Patients At Low or Intermediate Hemorrhagic Risk[edit | edit source]

Elective Procedure with Bare-metal Stent[edit | edit source]

• 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[edit | edit source]

• 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[edit | edit source]

• 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[edit | edit source]

Elective Procedure with Bare-Metal Stent Placement[edit | edit source]

• 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[edit | edit source]

• 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[edit | edit source]

CME Category::Cardiology