Effectiveness of Atrial Fibrillation as an Independent Predictor of Death and Coronary Events in Patients Having Coronary Angiography

doi:10.1016/j.amjcard.2008.08.028

The American Journal of Cardiology

Volume 103, Issue 1, 1 January 2009, Pages 36-40

https://doi.org/10.1016/j.amjcard.2008.08.028 Get rights and content

The impact of atrial fibrillation (AF) on future coronary events is uncertain. In particular, the prognostic impact of AF in the clinically important population of coronary patients who undergo angiography is unknown. The aim of this study was to investigate (1) the prevalence of AF, (2) its association with coronary atherosclerosis, and (3) its impact on future coronary events in patients who undergo angiography. Electrocardiograms were evaluated in a consecutive series of 613 patients who underwent coronary angiography. Prospectively, death and cardiovascular events were recorded over 4.0 ± 0.6 years. Among these patients, 37 (6%) at baseline had AF, and 576 (94%) were in sinus rhythm. The presence of AF was associated with a lower prevalence of coronary artery disease and of coronary diameter narrowing ≥50% on baseline angiography. However, prospectively, patients with AF were at a strongly increased risk for all-cause mortality (adjusted hazard ratio 5.15, 95% confidence interval 2.36 to 11.26, p <0.001), coronary death (hazard ratio 8.16, 95% confidence interval 2.89 to 23.09, p <0.001), and major coronary events (hazard ratio 3.80, 95% confidence interval 1.45 to 9.94, p = 0.007). In conclusion, although inversely associated with the presence of angiographically determined coronary atherosclerosis, AF is a strong predictor of death and future coronary events in patients with coronary artery disease who undergo coronary angiography.

Section snippets

Methods

The design of this prospective cohort study has been described in detail previously.8, 9 In short, we enrolled 613 consecutive Caucasian patients, 414 men and 199 postmenopausal women, who were referred to coronary angiography for the evaluation of established or suspected stable CAD from November 1999 to October 2000. Referral to coronary angiography was based on a clinical indication according to current guidelines.¹⁰ Patients who had acute coronary syndromes <3 months before baseline

Results

Baseline demographic data of our 613 patients were characteristic for a cohort of patients who underwent coronary angiography for the evaluation of CAD. Among our patients, 37 (6%) at baseline had AF (83.8% had permanent AF and 16.2% paroxysmal AF), and 576 (94%) were in sinus rhythm. The baseline characteristics of patients with AF and patients in sinus rhythm are listed in Table 1.

The prevalence of any CAD (62.2% vs 82.6%, p <0.001) as well as the prevalence of significant stenoses (18.9% vs

Discussion

From our data, we conclude that AF is a strong predictor of death and of future coronary events in an unselected population of consecutively studied patients who underwent coronary angiography. Surprisingly, AF conferred an increased risk for mortality and coronary events, although it was inversely associated with the presence of angiographically diagnosed CAD at baseline.

Our study for the first time investigated the association between AF and the angiographically determined presence of CAD. We

Acknowledgment

We wish to thank W. Benzer, MD, H. Holzmueller, MD, W. Fuchs, MD, and W. Metzler, MD, for performing expert coronary angiography. We thank Dr. E. Frommelt and the Innovationsstiftung of the Liechtenstein Global Trust Bank (Bendern, Liechtenstein), Dr. K.J. Hier, Peter Goop Stiftung (Vaduz, Liechtenstein), and Medizinisches Zentrallabor Feldkirch (Feldkirch, Austria). We are grateful to F. Rauch, P. Woess, MD, the Vorarlberger Aerztekammer (Dornbirn, Austria), and to L. Patsch, former director

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Cited by (17)

Atrial fibrillation and ischemic heart disease: beyond stroke prevention
2020, Revista Espanola de Cardiologia Suplementos
El objetivo principal en el abordaje del paciente con fibrilación auricular es la reducción del riesgo de ictus mediante el tratamiento antitrombótico adecuado. Sin embargo, a pesar de una adecuada anticoagulación, sigue habiendo un importante riesgo residual de eventos isquémicos, particularmente infarto de miocardio y muerte de origen cardiovascular, que exige una protección más completa. Por lo tanto, en el paciente con fibrilación auricular, el tratamiento anticoagulante debería perseguir este doble objetivo, la reducción tanto del riesgo de ictus como de las complicaciones isquémicas. Diferentes estudios han demostrado que los antagonistas de la vitamina K solo disminuyen el riesgo de ictus y de eventos isquémicos cuando el control de la anticoagulación es óptimo, cosa que ocurre en un pequeño número de pacientes. Con respecto a los anticoagulantes orales de acción directa, aunque en general muestran un perfil de eficacia y seguridad mejor que los antagonistas de la vitamina K, parece que no todos ofrecerían la misma protección en cuanto a la reducción de los eventos isquémicos. Está demostrado que el rivaroxabán reduce de manera significativa (18%) el riesgo de infarto de miocardio. De hecho, los estudios muestran que el rivaroxabán proporciona una protección vascular más completa en diferentes contextos clínicos, no solo en el paciente con fibrilación auricular, sino también en el paciente con enfermedad vascular ateroesclerótica.
The main aim of management in patients with atrial fibrillation is to reduce the risk of stroke using appropriate antithrombotic treatment. However, despite adequate anticoagulation, there remains a substantial residual risk of ischemic events, particularly myocardial infarction and cardiovascular death. A more general approach is needed. Consequently, in patients with atrial fibrillation, anticoagulation treatment should seek to achieve the twin targets of reducing the risk of both stroke and ischemic events. Studies have demonstrated that vitamin K antagonists reduce the risk of stroke and ischemic events only when anticoagulation control is optimal, a situation that occurs in only a small number of patients. Direct oral anticoagulants are generally more effective and safer than vitamin K antagonists. However, not all direct oral anticoagulants appear to offer the same protection against ischemic events. It has been shown that rivaroxaban significantly reduces the risk of myocardial infarction (by 18%). In fact, studies demonstrate that rivaroxaban provides comprehensive vascular protection across a range of clinical scenarios, not only in patients with atrial fibrillation, but also in those with atherosclerotic vascular disease.
Effectiveness and Safety of Anticoagulants in Adults with Non-valvular Atrial Fibrillation and Concomitant Coronary/Peripheral Artery Disease
2018, American Journal of Medicine
Citation Excerpt :
Patients with coronary and peripheral artery disease are at high risk for stroke, myocardial infarction, and cardiovascular-related death.10–13 Concomitant atrial fibrillation with coronary artery disease is associated with all-cause mortality, coronary death, and major coronary events.14 Atrial fibrillation management is complicated by the presence of concomitant coronary and peripheral artery disease.15
Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy and safety among patients with nonvalvular atrial fibrillation. Limited evidence is available regarding outcomes for nonvalvular atrial fibrillation patients with coronary/peripheral artery disease.
Non-valvular atrial fibrillation patients aged ≥65 years diagnosed with coronary/peripheral artery disease in the US Medicare population, newly initiating DOACs (apixaban, rivaroxaban, dabigatran) or warfarin were selected from January 1, 2013 to September 30, 2015. Propensity score matching was used to compare DOACs vs warfarin. Cox proportional hazards models were used to estimate the risk of stroke/systemic embolism, major bleeding, and composite of stroke/myocardial infarction/all-cause mortality.
There were 15,527 apixaban-warfarin, 6,962 dabigatran-warfarin, and 25,903 rivaroxaban-warfarin–matched pairs, with a mean follow-up of 5-6 months. Compared with warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.48; 95% confidence interval [CI], 0.37-0.62), major bleeding (HR 0.66; 95% CI, 0.58-0.75), and stroke/myocardial infarction/all-cause mortality (HR 0.63; 95% CI, 0.58-0.69); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (HR 0.79; 95% CI, 0.70-0.90 and HR 0.87; 95% CI, 0.81-0.92, respectively). Rivaroxaban was associated with a lower rate of stroke/systemic embolism (HR 0.72; 95% CI, 0.60-0.89) and a higher rate of major bleeding (HR 1.14; 95% CI, 1.05-1.23) vs warfarin.
All DOACs were associated with lower stroke/myocardial infarction/all-cause mortality rates compared with warfarin; differences were observed in rates of stroke/systemic embolism and major bleeding. Findings from this observational analysis provide important insights about oral anticoagulation therapy among non-valvular atrial fibrillation patients with coronary/peripheral artery disease and may help physicians in the decision-making process when treating this high-risk group of patients.
Looking for coronary disease in patients with atrial fibrillation
2014, Canadian Journal of Cardiology
Impact of periprocedural atrial fibrillation on short-term clinical outcomes following percutaneous coronary intervention
2012, American Journal of Cardiology
Citation Excerpt :
Our findings of a fourfold increase in 30-day mortality in the AF group and excess overall major adverse cardiac events and readmissions are consistent with other reports.2,3 Even in patients undergoing coronary angiography, presence of AF portends a poorer prognosis.12 In a study of 414 propensity-scored matched patients with AF grouped according to whether they received drug-eluting or bare-metal stents, Ruiz-Nodar et al13 identified chronic AF as a multivariate predictor of long-term major adverse cardiac events and all-cause mortality, but no direct comparison between patients with AF and those with SR was performed.
There are few data on the incidence and clinical outcomes of patients with atrial fibrillation (AF) treated in the era of percutaneous coronary intervention (PCI). We analyzed 30-day clinical outcomes in 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 162 patients (4.9%). AF was associated with older age (74.1 ± 8.9 vs 63.9 ± 11.9 years, p <0.001), higher baseline serum creatinine (0.13 ± 0.14 vs 0.10 ± 0.13 mmol/L, p = 0.01), and lower left ventricular ejection fraction (49.5 ± 13.2% vs 53.4% ± 11.6%, p <0.001). Significantly more patients with AF had a history of heart failure and cerebrovascular and peripheral arterial diseases (p ≤0.01 for all comparisons). Periprocedural glycoprotein IIb/IIIa inhibitor (31.5% vs 31.4%, p = 0.98) and antithrombin use were not different between groups, but in-hospital bleeding complications were higher in patients with AF (5.0% vs 2.1%, p = 0.015). Fewer patients with AF received drug-eluting stents (p = 0.004). AF was associated with a greater than fourfold increase in 30-day mortality (9.9% vs 2.2%, p <0.0001) and readmission rates at 30 days (p = 0.01). Fewer patients with AF were on dual antiplatelet therapy at 30 days (86.3% vs 94.3%, p <0.0001), although 28.1% of patients with AF were on triple therapy (dual antiplatelet therapy plus oral anticoagulation). In conclusion, patients with periprocedural AF represent a very high-risk group. Excess 30-day morbidity and mortality after PCI may be due to the higher incidence of co-morbidities, bleeding complications, and suboptimal antiplatelet therapy.
Effect of Atrial Fibrillation on Outcome in Patients With Known or Suspected Coronary Artery Disease Referred for Exercise Stress Testing
2010, American Journal of Cardiology
Citation Excerpt :
In addition, we failed to find a significant association between AF and future nonfatal coronary events. Notwithstanding these controversies, previous reports agree that the combination of AF and CAD portends a higher mortality risk.6,8 Our study complements and expands on these observations by demonstrating a significant association of AF with all-cause mortality in patients with known or suspected CAD referred for exercise stress testing.
The association of atrial fibrillation (AF) with coronary artery disease (CAD) remains controversial. In addition, the relation of AF to myocardial ischemia and outcomes in patients with known or suspected CAD referred for exercise stress testing has been poorly explored. In this study, 17,100 patients aged ≥50 years with known or suspected CAD who underwent exercise electrocardiography (n = 11,911) or exercise echocardiography (n = 5,189) were evaluated. End points were all-cause mortality, nonfatal myocardial infarction, and coronary revascularization. Overall, 619 patients presented with AF at the time of the tests. Patients with AF who had interpretable electrocardiograms had a lower likelihood of exercise-induced ischemic ST-segment abnormalities (adjusted odds ratio 0.51, 95% confidence interval 0.34 to 0.76, p = 0.001), and those with AF who underwent exercise echocardiography had a lower likelihood of new or worsening exercise-induced wall motion abnormalities (adjusted odds ratio 0.62, 95% confidence interval 0.44 to 0.87, p = 0.006). During a mean follow-up period of 6.5 ± 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, despite being associated with an apparently lower likelihood of myocardial ischemia, AF was an independent predictor of all-cause mortality in patients with known or suspected CAD referred for exercise stress testing.
New-Onset Atrial Fibrillation Predicts Long-Term Mortality After Coronary Artery Bypass Graft
2010, Journal of the American College of Cardiology
We sought to investigate the association between new-onset atrial fibrillation after coronary artery bypass graft (CABG) (post-operative atrial fibrillation [POAF]) and long-term mortality in patients with no history of atrial fibrillation.
POAF predicts longer hospital stay and greater post-operative mortality.
A total of 16,169 consecutive patients with no history of AF who underwent isolated CABG at our institution between January 1, 1996, and December 31, 2007, were included in the study. All-cause mortality data were obtained from Social Security Administration death records. A multivariable Cox proportional hazards regression model was constructed to determine the independent impact of new-onset POAF on long-term survival after adjusting for several covariates. The covariates included age, sex, race, pre-operative risk factors (ejection fraction, New York Heart Association functional class, history of myocardial infarction, index myocardial infarction, stroke, chronic obstructive pulmonary disease, peripheral arterial disease, smoking, diabetes, renal failure, hypertension, dyslipidemia, creatinine level, dialysis, redo surgery, elective versus emergent CABG, any valvular disorder) and post-operative adverse events (stroke, myocardial infarction, acute respiratory distress syndrome, and renal failure), and discharge cardiac medications known to affect survival in patients with coronary disease.
New-onset AF occurred in 2,985 (18.5%) patients undergoing CABG. POAF independently predicted long-term mortality (hazard ratio: 1.21; 95% confidence interval: 1.12 to 1.32) during a mean follow-up of 6 years (range 0 to 12.5 years). This association remained true after excluding from the analysis those patients who died in-hospital after surgery (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32). Patients with POAF discharged on warfarin experienced reduced mortality during follow-up.
In this large cohort of patients, POAF predicted long-term mortality. Warfarin anticoagulation may improve survival in POAF.

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Coronary artery diseaseEffectiveness of Atrial Fibrillation as an Independent Predictor of Death and Coronary Events in Patients Having Coronary Angiography

Section snippets

Methods

Results

Discussion

Acknowledgment

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am Heart J

Int J Cardiol

J Electrocardiol

Chronic atrial fibrillation—epidemiologic features and 14 year follow-up: a case control study

Eur Heart J

Epidemiologic features of chronic atrial fibrillation: the Framingham study

N Engl J Med

Coronary artery disease
Effectiveness of Atrial Fibrillation as an Independent Predictor of Death and Coronary Events in Patients Having Coronary Angiography