Outcomes in Newly Diagnosed Atrial Fibrillation and History of Acute Coronary Syndromes: Insights from GARFIELD-AF.
BACKGROUND
Many patients with atrial fibrillation have concomitant coronary artery disease with or without acute coronary syndromes and are in need of additional antithrombotic therapy. There are few data on the long-term clinical outcome of atrial fibrillation patients with a history of acute coronary syndrome. This is a 2-year study of atrial fibrillation patients with or without a history of acute coronary syndromes.


METHODS
Adults with newly diagnosed atrial fibrillation and ≥1 investigator-defined stroke risk factor were enrolled in GARFIELD-AF between March 2010 and September 2015. The association between prior acute coronary syndromes and long-term outcomes was determined using a Cox proportional hazards model, adjusting for baseline risk factors, oral anticoagulation (OAC) ± antiplatelet (AP) therapy, and usual care.


RESULTS
Of 39,679 patients, 10.5% had a history of acute coronary syndromes. At 2-year follow-up, patients with prior acute coronary syndromes had higher adjusted risks of stroke/systemic embolism (hazard ratio [HR] 1.39; 95% confidence interval [CI], 1.08-1.78), major bleeding (HR 1.30; 95% CI, 0.95 -1.79), all-cause mortality (HR 1.34; 95% CI, 1.21 -1.49), cardiovascular mortality (HR 1.85; 95% CI, 1.51-2.26), and new acute coronary syndromes (HR 3.42; 95% CI, 2.62-4.45). Comparing antithrombotic therapy in the acute coronary syndromes vs no acute coronary syndromes groups, most patients received OAC ± AP: 60.8% vs 66.1%, but AP therapy was more likely in the acute coronary syndromes group (68.1% vs 32.9%), either alone (34.9% vs 20.8%) or with OAC (33.2% vs 12.1%). Overall, 17.8% in the acute coronary syndromes group received dual AP therapy with (5.3%) or without OAC (12.5%). Among patients with moderate/high risk for stroke/systemic embolism, fewer in the acute coronary syndromes group received OAC with or without AP therapy (Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke, TIA, or thromboembolism, Vascular disease, Age 65-74 years, Sex category [CHA2DS2-VASc] 2: 52.1% vs 64.6%; CHA2DS2-VASc ≥3: 62.0% vs 70.7%), and the majority with a Hypertension (uncontrolled systolic blood pressure >160 mm Hg), Abnormal renal or liver function, previous Stroke, Bleeding history or predisposition, Labile international normalized ratios, Elderly, and concomitant Drugs or alcohol excess (HAS-BLED) score ≥3 were on AP therapy (83.8% vs 65.5%).


CONCLUSIONS
In GARFIELD-AF, previous acute coronary syndromes are associated with worse 2-year outcomes and a greater likelihood of under-treatment with OAC, while two-thirds of patients receive AP therapy. Major bleeding was more common with previous acute coronary syndromes, even after adjusting for all risk factors.
['Verheugt|Freek W A|FWA|', 'Ambrosio|Giuseppe|G|', 'Atar|Dan|D|', 'Bassand|Jean-Pierre|JP|', 'Camm|A John|AJ|', 'Costabel|Juan Pablo|JP|', 'Fitzmaurice|David A|DA|', 'Illingworth|Laura|L|', 'Goldhaber|Samuel Z|SZ|', 'Goto|Shinya|S|', 'Haas|Sylvia|S|', 'Jansky|Petr|P|', 'Kayani|Gloria|G|', 'Stepinska|Janina|J|', 'Turpie|Alexander G G|AGG|', 'van Eickels|Martin|M|', 'Kakkar|Ajay K|AK|', '|||']
D054058:Acute Coronary Syndrome D000368:Aged D000925:Anticoagulants D001281:Atrial Fibrillation D002318:Cardiovascular Diseases D002423:Cause of Death D005260:Female D005500:Follow-Up Studies D006470:Hemorrhage D006801:Humans D008297:Male D010975:Platelet Aggregation Inhibitors D011379:Prognosis D016016:Proportional Hazards Models D012307:Risk Factors D020521:Stroke
Stroke Anticoagulation Bleeding Mortality Antiplatelet therapy