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Antithrombotic therapy and outcomes of patients with atrial fibrillation following primary percutaneous coronary intervention: results from the APEX-AMI trial
European Heart Journal, 06/09/09

Lopes RD et al. – Atrial fibrillation (AF) prevalence at baseline and at discharge was 4.8% and 2.5%, respectively. The proportion of pts 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 pts undergoing primary percutaneous coronary intervention (PCI).

Methods

Study of AF incidence and timing of atrial fibrillation and to describe antithrombotic therapy use and evaluate association of AF with 90-day mortality and other secondary clinical outcomes
Subjects: 5745 ST-segment elevation myocardial infarction pts treated with primary PCI in APEX-AMI

Results

AF during hospitalization for ~11% of pts
AF prevalence: 4.8% at baseline and 2.5% at discharge
Proportion of 5466 pts without AF at baseline who developed new onset AF: 6.3%; 9.3 cases of new onset AF/1000 pt days at risk
New onset AF independently associated with 90-day mortality after accounting for baseline covariates and in-hospital procedures and complications
New onset AF associated with shock, congestive heart failure, and stroke in models accounting for baseline covariates
Of AF pts, 55% did not receive oral anticoagulation therapy at discharge
Of pts with coronary stents, 5.1% discharged on triple therapy
Pts at highest risk of stroke (CHADS2 score ≥2) least likely to receive oral anticoagulation at discharge (39%)
Warfarin use in pts with AF at discharge (43.4%) associated with lower rates of 90-day mortality and stroke

Exclusive Author Commentary
Renato D. Lopes, 06/17/09

In this study we were able to examine atrial fibrillation in the setting of acute myocardial infarction treated with primary PCI. We assessed its timing (present at presentation, new onset, and at discharge) and also described the associated use of antithrombotic therapy. An important feature of this study is that for the first time a comprehensive analysis was performed, adjusting for all possible baseline characteristics, in-hospital complications, and procedures, to assess the independent relationship of new onset AF with 90 day outcomes. Importantly, we found that patients with higher CHADS2 score were less likely to be treated with warfarin, highlighting the need for better understanding optimal antithrombotic therapy in patients with STEMI and AF. Although we found lower rates of stroke and death at 90 days in those patients with AF treated with warfarin, these results should be interpreted with caution since this was a not randomized comparison.

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