- Email: [email protected]
Usefulness of atrial fibrillation as a marker of outcome after percutaneous coronary intervention
Usefulness of Atrial Fibrillation as a Marker of Outcome After Percutaneous Coronary Intervention Magdi M. El-Omar, MBBS, MRCP, George Dangas, MD, PhD, Roxana Mehran, MD, Alexandra J. Lansky, MD, Nicholas N. Kipshidze, MD, PhD, Sotir Polena, MD, Martin Fahy, MSc, Issam Moussa, MD, Lynne Glasser, MD, Jeffrey W. Moses, MD, Gregg W. Stone, MD, and Martin B. Leon, MD trial fibrillation (AF) can adversely affect clinical outcomes after coronary artery bypass grafting A (CABG), other major noncardiac surgery, and 1,2
3
4
acute myocardial infarction (AMI). Although multiple predictors of an adverse outcome following percutaneous coronary intervention (PCI) have been identified,5 the prognostic significance of AF in the context of PCI is unknown. This study examined clinical outcomes after PCI in a large group of consecutive patients according to whether they were in AF or sinus rhythm at the time of the index PCI procedure. •••
The study population comprised 9,817 consecutive patients (17,862 lesions treated) from the Cardiovascular Research Foundation PCI Database who had not had an AMI in the preceding 72 hours and who underwent PCI of de novo lesions in native coronary arteries between January 1994 and January 1999. Baseline clinical demographics and in-hospital events were gathered prospectively by a dedicated data center and entered into the computerized database. Clinical outcomes were prospectively collected after hospital discharge through written questionnaire, telephone, and/or office interview. All adverse events were adjudicated after review of relevant source documents. Patients were divided into 2 groups according to the presence or absence of AF on the electrocardiogram taken at the time of PCI. There were 426 patients with AF, and 9,391 patients in sinus rhythm. Anginal symptoms were classified according to the Canadian Cardiovascular Society guidelines.6 Q-wave AMI was defined as the presence of new Q waves on the postprocedure electrocardiogram, and non–Q-wave AMI was defined as at least a fivefold increase above the upper limit of normal of the serum creatine kinase-MB fraction (without new Q waves). The choice of PCI rather than medical therapy or surgical revascularization was made by the attending cardiologist. Angiographic success was defined as a reduction of the stenosis by ⱖ20% and to ⬍50% in all lesions. Procedural success was defined as angiographic success in the absence of major in-hospital complications (death, Q-wave MI, and emergency byFrom the Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, New York, New York. Dr. Dangas’ address is: Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, 55 East 59th Street, 6th Floor, New York, New York 10022. E-mail: [email protected]. Manuscript received April 15, 2002; revised manuscript received and accepted September 12, 2002.
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©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 91 January 15, 2003
TABLE 1 Baseline Clinical Characteristics AF (n ⫽ 426)
Sinus Rhythm (n ⫽ 9,391)
Men 67.1% 69.1% Caucasian 85.6% 84.3% Age (yrs) 70.9 ⫾ 8.9 63.9 ⫾ 11.2 Angina: Post-AMT 11.1% 10.7% Angina: Pain at rest 27.8% 25.3% CCS angina class III 21.6% 22.9% CCS angina class IV 38.7% 35.0% Prior AMI 54.8% 50.5% Prior CABG 47.8% 40.4% Prior PCI 43.7% 48.4% Left ventricular ejection 43 ⫾ 14% 47 ⫾ 13% fraction Systemic hypertension 74.6% 63.8% Diabetes mellitus 32.0% 31.5% Family history of ischemic 50.8% 61.3% heart disease Hypercholesterolemia (total 59.1% 70.9% cholesterol ⬎250 mg/dl) Peripheral vascular disease 35.9% 22.3% Prior stroke 23.3% 11.5% Cigarette smoking 56.8% 58.2% Chronic heart failure NYHA 5.0% 2.7% class III Chronic heart failure NYHA 4.5% 1.2% class IV Chronic renal insufficiency 16.0% 8.3% (serum creatinine ⬎2.0 mg/dl) Warfarin therapy 40.8% 15.7%
p Value 0.42 0.51 ⬍0.0001 0.80 0.25 0.53 0.12 0.08 0.003 0.06 ⬍0.0001 ⬍0.0001 0.81 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 0.56 0.005 ⬍0.0001 ⬍0.0001 ⬍0.0001
CCS ⫽ Canadian Cardiovascular Society; NYHA ⫽ New York Heart Association.
pass surgery). All patients received 325 mg of aspirin orally ⱖ2 hours before the procedure and daily thereafter. Patients on warfarin had this terminated 2 to 3 days before the procedure to ensure an international normalized ratio ⬍2 at the time of PCI. After stent placement, ticlopidine (250 mg twice daily) or clopidogrel (75 mg/day) was given routinely for 4 weeks. Warfarin was continued long-term in patients who were taking it before the PCI. Glycoprotein IIb/IIIa inhibitors were used in ⬍7% of the patients in both treatment groups. The activated clotting time was maintained at 300 seconds for the duration of the procedure, unless glycoprotein IIb/IIIa inhibitors were used. Twelve-lead electrocardiograms were obtained at baseline, within 4 hours after the procedure, and on the following day (and more frequently if creatine kinase-MB was elevated or recurrent chest pain de0002-9149/03/$–see front matter PII S0002-9149(02)03114-4
TABLE 2 Procedural Data and In-hospital Events
Angiographic success Multivessel PCI (ⱖ2 vessels) Stent use Preprocedure minimal lumen diameter (mm) Final minimal lumen diameter (mm) Abrupt closure No reflow Thrombus Distal embolization Death Q-wave AMI Non–Q-wave AMI In-hospital CABG In-hospital major adverse cardiac events Neurologic event Vascular complication Contrast nephropathy Gastrointestinal bleed Blood transfusion Intensive care unit stay (d) Length of hospital stay after procedure (d)
AF (n ⫽ 426)
Sinus Rhythm (n ⫽ 9,391)
97.9% 25% 58% 0.87 ⫾ 0.10 0.09 ⫾ 0.17 0.7% 0.5% 0.4% 0.4% 1.9% 0.2% 11.0% 0.7% 1.9% 4.2% 8.2% 7.8% 1.4% 9.8% 1.00 ⫾ 3.16 3.58 ⫾ 4.89
97.8% 23.5% 57% 0.86 ⫾ 0.11 0.09 ⫾ 0.17 0.7% 0.8% 1.6% 0.5% 0.7% 0.3% 12.2% 1.4% 2.1% 1.8% 4.0% 2.7% 0.8% 5.5% 0.41 ⫾ 1.78 2.41 ⫾ 3.66
Relative Risk (95% CI) 1.00 0.90 0.98 0.67 0.85 0.96 0.64 0.28 0.89 2.67 0.69 0.90 0.49 0.89 2.38 2.03 2.95 1.79 1.80 0.59 1.17
p Value
(0.99–1.02) (0.82–1.44) (0.88–1.26) (0.44–1.01) (0.66–1.11) (0.39–2.34) (0.24–1.73) (0.04–1.96) (0.12–6.46) (1.29–5.53) (0.09–5.04) (0.67–1.20) (0.16–1.53) (0.44–1.79) (1.48–3.83) (1.46–2.83) (2.08–4.19) (0.78–4.09) (1.33–2.45) (0.41–0.78) (0.81–1.53)
0.92 0.92 1 0.04 0.27 0.92 0.38 0.27 1 0.01 1 0.46 0.21 0.74 0.0003 ⬍0.0001 ⬍0.0001 0.16 0.0002 0.0002 ⬍0.0001
CI ⫽ confidence interval.
mated edge-detection algorithm (CMS, MEDIS, Leiden, The NetherAF Sinus Rhythm Relative Risk lands) as previously described.7 (n ⫽ 390) (n ⫽ 8,955) (95% CI) p Value Statistical analysis was performed using SAS software (SAS Institute Death from all causes 10.3% 5.9% 1.75 (1.29–2.37) 0.0004 Q-wave AMI 0.6% 1.0% 0.57 (0.14–2.32) 0.59 Inc., Cary, North Carolina). CategorTarget lesion revascularization 13.2% 19.0% 0.70 (0.53–0.91) 0.007 ical variables are presented as per(all) cent frequencies and compared by Target lesion (CABG) 2.8% 5.6% 0.51 (0.27–0.94) 0.03 chi-square analysis or Fisher’s exact Target lesion revascularization 10.7% 14.2% 0.75 (0.56–1.02) 0.06 (PCI) test. Continuous variables are preMajor adverse cardiac events 22.3% 23.4% 0.95 (0.79–1.15) 0.62 sented as mean ⫾ 1 SD and compared with Student’s t test or MannAbbreviation as in Table 2. Whitney U test. Multivariate logistic regression analysis was used to determine the independent predictors of in-hospital mortality; 1-year mortality modeling TABLE 4 Adjusted Relative Risks of In-hospital Major Adverse was performed with the Cox proportional hazards Cardiac Events regression method. After univariate logistic regression Odds was performed, variables with a p value ⬍0.2 were Ratio 95% CI p Value entered into the multivariate model. A p value of Left ventricular ejection fraction 0.06 0.01–0.26 0.0002 ⬍0.05 was considered statistically significant. Age 1.02 1–1.04 0.05 The baseline clinical characteristics of the 2 groups AF 0.79 0.31–1.97 0.60 of patients are listed in Table 1. Patients with AF were Men 0.93 0.60–1.43 0.73 older, had lower left ventricular ejection fractions, and Chronic renal impairment 0.95 0.52–1.75 0.87 Diabetes mellitus 1.19 0.79–1.80 0.40 higher rates of hypertension, peripheral vascular disCigarette smoking 0.78 0.52–1.17 0.22 ease, prior stroke, severe heart failure, chronic renal History of cerebrovascular accident 1.30 0.78–2.18 0.31 impairment, and a history of CABG, compared with Hypertension 1.02 0.67–1.57 0.91 patients in sinus rhythm. Hypercholesterolemia, a posSevere heart failure 1.36 0.49–3.75 0.56 itive family history for ischemic heart disease, and a Abbreviation as in Table 2. presentation with unstable angina were more common in patients in sinus rhythm. Procedural data and in-hospital events are listed in veloped). Other medications and decisions regarding Table 2. The rates of angiographic success were similar between the 2 groups. The rates of death, neurotiming of discharge were left to the operator. Cineangiograms were analyzed by a dedicated logic events (including transient ischemic attacks and team of independent observers who were blinded to cerebrovascular accidents), major vascular complicathe clinical findings, using a computer-assisted, auto- tions (including limb ischemia, pseudoaneurysm forTABLE 3 Unadjusted Relative Risks of Major Adverse Events After One Year
BRIEF REPORTS
233
TABLE 5 Adjusted Relative Risks of Major Adverse Cardiac Events After One Year Odds Ratio Left ventricular ejection fraction Chronic renal impairment Diabetes mellitus AF Men Age Cigarette smoking History of cerebrovascular accident Hypertension Severe heart failure
0.44 1.45 1.47 0.83 1.08 0.10 0.92 1.03 1.06 1.36
95% CI
p Value
0.27–0.73 0.001 1.17–1.79 0.0007 1.28–1.69 ⬍0.0001 0.60–1.14 0.25 0.94–1.25 0.28 0.99–1.00 0.22 0.80–1.05 0.21 0.85–1.25 0.76 0.93–1.22 0.39 0.93–1.98 0.11
Abbreviation as in Table 2.
TABLE 6 Adjusted Relative Risks of One-year Mortality
Left ventricular ejection fraction Age Chronic renal impairment Diabetes mellitus Severe heart failure Hypertension History of cerebrovascular accident Men AF Cigarette smoking
(2) that such an increased risk cannot be attributed to the AF per se, but rather to other comorbid conditions commonly associated with it. As such, AF may be viewed as a readily available, useful marker, and not an independent predictor, of an adverse cardiac outcome after PCI. It is particularly noteworthy that patients with AF had a higher rate of in-hospital thromboembolic neurologic complications compared with patients in sinus rhythm. This finding, which is characteristic of patients with AF in general,8 is likely to be related to the hypercoagulable state known to exist in AF.9 A hypercoagulable state is also found in other conditions that often coexist with atrial fibrillation, including coronary artery disease,10 hypertension,11 diabetes mellitus,12 chronic heart failure,13 chronic renal impairment,14 and hypercholesterolemia.15
Odds Ratio
95% CI
p Value
0.02 1.04 2.65 1.89 1.95 1.40 1.42 0.80 1.13 0.99
0.01–0.05 1.02–1.05 2.00–3.51 1.49–2.39 1.18–3.21 1.06–1.83 1.06–1.89 0.63–1.03 0.71–1.77 0.78–1.26
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 0.01 0.02 0.02 0.09 0.61 0.92
In conclusion, AF appears to be a useful, readily available marker of unfavorable short- and longterm outcome after PCIs. However, the increased risk in these patients is due to the associated risk factors rather than the AF itself.
Abbreviation as in Table 2. 1. Hogue CW Jr, Hyder ML. Atrial fibrillation after
mation, ultrasound vascular repair, retroperitoneal bleeds, gastrointestinal bleeds, and the need for blood transfusion), and post-PCI contrast nephropathy (an increase in serum creatinine by ⱖ25% over baseline value) were significantly higher in the AF group compared with the sinus rhythm group. Length of hospital stay following PCI was significantly longer for the AF group, reflecting the higher incidence of in-hospital postprocedural complications and also the longer stay in the intensive care unit. The 1-year follow-up rate for both groups was 91%. Table 3 lists the unadjusted relative risks for major adverse events at 1-year follow-up. Patients with AF had a greater risk of dying from all causes compared with the sinus rhythm group, whereas the latter had a lower rate of target lesion revascularization. However, multivariate analysis showed that age, low left ventricular ejection fraction, severe heart failure, chronic renal insufficiency, diabetes mellitus, history of cerebrovascular accident, and history of hypertension were independent predictors of ⱖ1 in-hospital major adverse cardiac event, 1-year major adverse cardiac events, or 1-year mortality, whereas AF was not independently predictive of any of the investigated outcomes (Tables 4 to 6). •••
This study showed that: (1) patients with AF have a higher rate of short- and long-term complications after PCI compared with patients in sinus rhythm, and
234 THE AMERICAN JOURNAL OF CARDIOLOGY姞
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cardiac operation: risks, mechanisms, and treatment. Ann Thorac Surg 2000;69:300 –306. 2. Stamou SC, Dangas G, Hill PC, Pfister AJ, Dullum MK, Boyce SW, Bafi AS, Garcia JM, Corso PJ. Atrial fibrillation after beating heart surgery. Am J Cardiol 2000;86:64 –67. 3. Polanczyk CA, Goldman L, Marcantonio ER, Orav EJ, Lee TH. Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay. Ann Intern Med 1998;129:279 –285. 4. Rathore SS, Berger AK, Weinfurt KP, Schulman KA, Oetgen WJ, Gersh BJ, Solomon AJ. Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation 2000;101:969 –974. 5. Smith SC Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, et al. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)— executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty) endorsed by the Society for Cardiac Angiography and Interventions. Circulation 2001;103:3019 – 3041. 6. Campeau L. Grading of angina pectoris (letter). Circulation 1976;54:522–523. 7. Lansky AJ, Popma JJ. Qualitative and quantitative angiography. In: Topol E, ed. Textbook of Interventional Cardiology. Philadelphia, PA: WB Saunders, 1999:725–747. 8. Chesebro JH, Fuster V, Halperin JL. Atrial fibrillation-risk marker for stroke. N Engl J Med 1990;323:1556 –1558. 9. Lip GY. Does atrial fibrillation confer a hypercoagulable state? Lancet 1995; 346:1313–1314. 10. Feng D, D’Agostino RB, Silbershatz H, Lipinska I, Massaro J, Levy D, Benjamin EJ, Wolf PA, Totler GH. Haemostatic state and atrial fibrillation (The Framingham Offspring Study). Am J Cardiol 2001;87:168 –171. 11. Lip GY, Edmunds E, Beevers DG. Should patients with hypertension receive antithrombotic therapy? J Intern Med 2001;249:205–214. 12. Carr ME. Diabetes mellitus: a hypercoagulable state. J Diabetes Complications 2001;15:44 –54. 13. Garg RK, Gheorghiade M, Jafri SM. Antiplatelet and anticoagulant therapy in the prevention of thromboemboli in chronic heart failure. Prog Cardiovasc Dis 1998;41:225–236. 14. Vaziri ND, Gonzales EC, Wang J, Said S. Blood coagulation, fibrinolytic, and inhibitory proteins in end-stage renal disease: effect of hemodialysis. Am J Kidney Dis 1994;23:828 –835. 15. Schafer AI. The hypercoagulable states. Ann Intern Med 1985;102:814 –828.
JANUARY 15, 2003
3
4
acute myocardial infarction (AMI). Although multiple predictors of an adverse outcome following percutaneous coronary intervention (PCI) have been identified,5 the prognostic significance of AF in the context of PCI is unknown. This study examined clinical outcomes after PCI in a large group of consecutive patients according to whether they were in AF or sinus rhythm at the time of the index PCI procedure. •••
The study population comprised 9,817 consecutive patients (17,862 lesions treated) from the Cardiovascular Research Foundation PCI Database who had not had an AMI in the preceding 72 hours and who underwent PCI of de novo lesions in native coronary arteries between January 1994 and January 1999. Baseline clinical demographics and in-hospital events were gathered prospectively by a dedicated data center and entered into the computerized database. Clinical outcomes were prospectively collected after hospital discharge through written questionnaire, telephone, and/or office interview. All adverse events were adjudicated after review of relevant source documents. Patients were divided into 2 groups according to the presence or absence of AF on the electrocardiogram taken at the time of PCI. There were 426 patients with AF, and 9,391 patients in sinus rhythm. Anginal symptoms were classified according to the Canadian Cardiovascular Society guidelines.6 Q-wave AMI was defined as the presence of new Q waves on the postprocedure electrocardiogram, and non–Q-wave AMI was defined as at least a fivefold increase above the upper limit of normal of the serum creatine kinase-MB fraction (without new Q waves). The choice of PCI rather than medical therapy or surgical revascularization was made by the attending cardiologist. Angiographic success was defined as a reduction of the stenosis by ⱖ20% and to ⬍50% in all lesions. Procedural success was defined as angiographic success in the absence of major in-hospital complications (death, Q-wave MI, and emergency byFrom the Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, New York, New York. Dr. Dangas’ address is: Cardiovascular Research Foundation, Lenox Hill Heart and Vascular Institute, 55 East 59th Street, 6th Floor, New York, New York 10022. E-mail: [email protected]. Manuscript received April 15, 2002; revised manuscript received and accepted September 12, 2002.
232
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 91 January 15, 2003
TABLE 1 Baseline Clinical Characteristics AF (n ⫽ 426)
Sinus Rhythm (n ⫽ 9,391)
Men 67.1% 69.1% Caucasian 85.6% 84.3% Age (yrs) 70.9 ⫾ 8.9 63.9 ⫾ 11.2 Angina: Post-AMT 11.1% 10.7% Angina: Pain at rest 27.8% 25.3% CCS angina class III 21.6% 22.9% CCS angina class IV 38.7% 35.0% Prior AMI 54.8% 50.5% Prior CABG 47.8% 40.4% Prior PCI 43.7% 48.4% Left ventricular ejection 43 ⫾ 14% 47 ⫾ 13% fraction Systemic hypertension 74.6% 63.8% Diabetes mellitus 32.0% 31.5% Family history of ischemic 50.8% 61.3% heart disease Hypercholesterolemia (total 59.1% 70.9% cholesterol ⬎250 mg/dl) Peripheral vascular disease 35.9% 22.3% Prior stroke 23.3% 11.5% Cigarette smoking 56.8% 58.2% Chronic heart failure NYHA 5.0% 2.7% class III Chronic heart failure NYHA 4.5% 1.2% class IV Chronic renal insufficiency 16.0% 8.3% (serum creatinine ⬎2.0 mg/dl) Warfarin therapy 40.8% 15.7%
p Value 0.42 0.51 ⬍0.0001 0.80 0.25 0.53 0.12 0.08 0.003 0.06 ⬍0.0001 ⬍0.0001 0.81 ⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 0.56 0.005 ⬍0.0001 ⬍0.0001 ⬍0.0001
CCS ⫽ Canadian Cardiovascular Society; NYHA ⫽ New York Heart Association.
pass surgery). All patients received 325 mg of aspirin orally ⱖ2 hours before the procedure and daily thereafter. Patients on warfarin had this terminated 2 to 3 days before the procedure to ensure an international normalized ratio ⬍2 at the time of PCI. After stent placement, ticlopidine (250 mg twice daily) or clopidogrel (75 mg/day) was given routinely for 4 weeks. Warfarin was continued long-term in patients who were taking it before the PCI. Glycoprotein IIb/IIIa inhibitors were used in ⬍7% of the patients in both treatment groups. The activated clotting time was maintained at 300 seconds for the duration of the procedure, unless glycoprotein IIb/IIIa inhibitors were used. Twelve-lead electrocardiograms were obtained at baseline, within 4 hours after the procedure, and on the following day (and more frequently if creatine kinase-MB was elevated or recurrent chest pain de0002-9149/03/$–see front matter PII S0002-9149(02)03114-4
TABLE 2 Procedural Data and In-hospital Events
Angiographic success Multivessel PCI (ⱖ2 vessels) Stent use Preprocedure minimal lumen diameter (mm) Final minimal lumen diameter (mm) Abrupt closure No reflow Thrombus Distal embolization Death Q-wave AMI Non–Q-wave AMI In-hospital CABG In-hospital major adverse cardiac events Neurologic event Vascular complication Contrast nephropathy Gastrointestinal bleed Blood transfusion Intensive care unit stay (d) Length of hospital stay after procedure (d)
AF (n ⫽ 426)
Sinus Rhythm (n ⫽ 9,391)
97.9% 25% 58% 0.87 ⫾ 0.10 0.09 ⫾ 0.17 0.7% 0.5% 0.4% 0.4% 1.9% 0.2% 11.0% 0.7% 1.9% 4.2% 8.2% 7.8% 1.4% 9.8% 1.00 ⫾ 3.16 3.58 ⫾ 4.89
97.8% 23.5% 57% 0.86 ⫾ 0.11 0.09 ⫾ 0.17 0.7% 0.8% 1.6% 0.5% 0.7% 0.3% 12.2% 1.4% 2.1% 1.8% 4.0% 2.7% 0.8% 5.5% 0.41 ⫾ 1.78 2.41 ⫾ 3.66
Relative Risk (95% CI) 1.00 0.90 0.98 0.67 0.85 0.96 0.64 0.28 0.89 2.67 0.69 0.90 0.49 0.89 2.38 2.03 2.95 1.79 1.80 0.59 1.17
p Value
(0.99–1.02) (0.82–1.44) (0.88–1.26) (0.44–1.01) (0.66–1.11) (0.39–2.34) (0.24–1.73) (0.04–1.96) (0.12–6.46) (1.29–5.53) (0.09–5.04) (0.67–1.20) (0.16–1.53) (0.44–1.79) (1.48–3.83) (1.46–2.83) (2.08–4.19) (0.78–4.09) (1.33–2.45) (0.41–0.78) (0.81–1.53)
0.92 0.92 1 0.04 0.27 0.92 0.38 0.27 1 0.01 1 0.46 0.21 0.74 0.0003 ⬍0.0001 ⬍0.0001 0.16 0.0002 0.0002 ⬍0.0001
CI ⫽ confidence interval.
mated edge-detection algorithm (CMS, MEDIS, Leiden, The NetherAF Sinus Rhythm Relative Risk lands) as previously described.7 (n ⫽ 390) (n ⫽ 8,955) (95% CI) p Value Statistical analysis was performed using SAS software (SAS Institute Death from all causes 10.3% 5.9% 1.75 (1.29–2.37) 0.0004 Q-wave AMI 0.6% 1.0% 0.57 (0.14–2.32) 0.59 Inc., Cary, North Carolina). CategorTarget lesion revascularization 13.2% 19.0% 0.70 (0.53–0.91) 0.007 ical variables are presented as per(all) cent frequencies and compared by Target lesion (CABG) 2.8% 5.6% 0.51 (0.27–0.94) 0.03 chi-square analysis or Fisher’s exact Target lesion revascularization 10.7% 14.2% 0.75 (0.56–1.02) 0.06 (PCI) test. Continuous variables are preMajor adverse cardiac events 22.3% 23.4% 0.95 (0.79–1.15) 0.62 sented as mean ⫾ 1 SD and compared with Student’s t test or MannAbbreviation as in Table 2. Whitney U test. Multivariate logistic regression analysis was used to determine the independent predictors of in-hospital mortality; 1-year mortality modeling TABLE 4 Adjusted Relative Risks of In-hospital Major Adverse was performed with the Cox proportional hazards Cardiac Events regression method. After univariate logistic regression Odds was performed, variables with a p value ⬍0.2 were Ratio 95% CI p Value entered into the multivariate model. A p value of Left ventricular ejection fraction 0.06 0.01–0.26 0.0002 ⬍0.05 was considered statistically significant. Age 1.02 1–1.04 0.05 The baseline clinical characteristics of the 2 groups AF 0.79 0.31–1.97 0.60 of patients are listed in Table 1. Patients with AF were Men 0.93 0.60–1.43 0.73 older, had lower left ventricular ejection fractions, and Chronic renal impairment 0.95 0.52–1.75 0.87 Diabetes mellitus 1.19 0.79–1.80 0.40 higher rates of hypertension, peripheral vascular disCigarette smoking 0.78 0.52–1.17 0.22 ease, prior stroke, severe heart failure, chronic renal History of cerebrovascular accident 1.30 0.78–2.18 0.31 impairment, and a history of CABG, compared with Hypertension 1.02 0.67–1.57 0.91 patients in sinus rhythm. Hypercholesterolemia, a posSevere heart failure 1.36 0.49–3.75 0.56 itive family history for ischemic heart disease, and a Abbreviation as in Table 2. presentation with unstable angina were more common in patients in sinus rhythm. Procedural data and in-hospital events are listed in veloped). Other medications and decisions regarding Table 2. The rates of angiographic success were similar between the 2 groups. The rates of death, neurotiming of discharge were left to the operator. Cineangiograms were analyzed by a dedicated logic events (including transient ischemic attacks and team of independent observers who were blinded to cerebrovascular accidents), major vascular complicathe clinical findings, using a computer-assisted, auto- tions (including limb ischemia, pseudoaneurysm forTABLE 3 Unadjusted Relative Risks of Major Adverse Events After One Year
BRIEF REPORTS
233
TABLE 5 Adjusted Relative Risks of Major Adverse Cardiac Events After One Year Odds Ratio Left ventricular ejection fraction Chronic renal impairment Diabetes mellitus AF Men Age Cigarette smoking History of cerebrovascular accident Hypertension Severe heart failure
0.44 1.45 1.47 0.83 1.08 0.10 0.92 1.03 1.06 1.36
95% CI
p Value
0.27–0.73 0.001 1.17–1.79 0.0007 1.28–1.69 ⬍0.0001 0.60–1.14 0.25 0.94–1.25 0.28 0.99–1.00 0.22 0.80–1.05 0.21 0.85–1.25 0.76 0.93–1.22 0.39 0.93–1.98 0.11
Abbreviation as in Table 2.
TABLE 6 Adjusted Relative Risks of One-year Mortality
Left ventricular ejection fraction Age Chronic renal impairment Diabetes mellitus Severe heart failure Hypertension History of cerebrovascular accident Men AF Cigarette smoking
(2) that such an increased risk cannot be attributed to the AF per se, but rather to other comorbid conditions commonly associated with it. As such, AF may be viewed as a readily available, useful marker, and not an independent predictor, of an adverse cardiac outcome after PCI. It is particularly noteworthy that patients with AF had a higher rate of in-hospital thromboembolic neurologic complications compared with patients in sinus rhythm. This finding, which is characteristic of patients with AF in general,8 is likely to be related to the hypercoagulable state known to exist in AF.9 A hypercoagulable state is also found in other conditions that often coexist with atrial fibrillation, including coronary artery disease,10 hypertension,11 diabetes mellitus,12 chronic heart failure,13 chronic renal impairment,14 and hypercholesterolemia.15
Odds Ratio
95% CI
p Value
0.02 1.04 2.65 1.89 1.95 1.40 1.42 0.80 1.13 0.99
0.01–0.05 1.02–1.05 2.00–3.51 1.49–2.39 1.18–3.21 1.06–1.83 1.06–1.89 0.63–1.03 0.71–1.77 0.78–1.26
⬍0.0001 ⬍0.0001 ⬍0.0001 ⬍0.0001 0.01 0.02 0.02 0.09 0.61 0.92
In conclusion, AF appears to be a useful, readily available marker of unfavorable short- and longterm outcome after PCIs. However, the increased risk in these patients is due to the associated risk factors rather than the AF itself.
Abbreviation as in Table 2. 1. Hogue CW Jr, Hyder ML. Atrial fibrillation after
mation, ultrasound vascular repair, retroperitoneal bleeds, gastrointestinal bleeds, and the need for blood transfusion), and post-PCI contrast nephropathy (an increase in serum creatinine by ⱖ25% over baseline value) were significantly higher in the AF group compared with the sinus rhythm group. Length of hospital stay following PCI was significantly longer for the AF group, reflecting the higher incidence of in-hospital postprocedural complications and also the longer stay in the intensive care unit. The 1-year follow-up rate for both groups was 91%. Table 3 lists the unadjusted relative risks for major adverse events at 1-year follow-up. Patients with AF had a greater risk of dying from all causes compared with the sinus rhythm group, whereas the latter had a lower rate of target lesion revascularization. However, multivariate analysis showed that age, low left ventricular ejection fraction, severe heart failure, chronic renal insufficiency, diabetes mellitus, history of cerebrovascular accident, and history of hypertension were independent predictors of ⱖ1 in-hospital major adverse cardiac event, 1-year major adverse cardiac events, or 1-year mortality, whereas AF was not independently predictive of any of the investigated outcomes (Tables 4 to 6). •••
This study showed that: (1) patients with AF have a higher rate of short- and long-term complications after PCI compared with patients in sinus rhythm, and
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