Atrial fibrillation in acute coronary syndromes

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

## Overview

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

## Epidemiology and Demographics

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

## Risk Factors

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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

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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

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### Current Practice Patterns Regarding the Patient with ACS and Atrial Fibrillation Among US Interventional Cardiologists in SCAI Survey

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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]

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* 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]

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#### Atrial fibrillation and a coronary stent with moderate/high stroke risk (CHADS2 ≥ 1)

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##### Low Risk of Stent Thrombosis and Low Bleeding Risk

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* 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

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* 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

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* 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]

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#### Anticoagulation In PCI Patients At Low or Intermediate Hemorrhagic Risk

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##### Elective Procedure with Bare-metal Stent

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* 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

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* 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

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* 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

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##### Elective Procedure with Bare-Metal Stent Placement

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* 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

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* 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

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1. ↑ 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.
2. ↑ Hersi et al. ANGIOLOGY August 2012 vol. 63 no. 6 466-471
3. ↑ Faxon D, Thrombosis & Hemostasis 2011;106(3):522-34
4. ↑ Faxon D, Thrombosis & Hemostasis 2011;106(3):522-34.
5. ↑ Faxon D, Thrombosis & Hemostasis 2011;106(3):522-34.
6. ↑ Thromb Haemost 2010;103:13–28

CME Category::Cardiology