European Heart Journal Advance Access published online on June 6, 2009
European Heart Journal, doi:10.1093/eurheartj/ehp213
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Antithrombotic therapy and outcomes of patients with atrial fibrillation following primary percutaneous coronary intervention: results from the APEX-AMI trial
1 Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Room 0311 Terrace Level, Durham, NC 27707, USA
2 Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
3 New York University School of Medicine, New York, NY, USA
4 Department of Cardiology, University Hospital Gasthuisberg and Leuven Coordinating Center, Leuven, Belgium
5 Divisione di Cardiologia, Ospedale Maggiore di Parma, Universita degli Studi di Parma, Parma, Italy
6 Department of Interventional Cardiology, Skejby University Hospital Brendstrupgaardsvej, Aarhus, Denmark
7 Department of Cardiology, Henry Ford Heart and Vascular Institute, Detroit, MI, USA
8 Charles University Hospital, Vinohrady Cardiocenter, Prague, Czech Republic
9 Division of Cardiology, University of Alberta, Edmonton, Alberta
Received 30 September 2008; revised 27 March 2009; accepted 4 May 2009 * Corresponding author. Tel: +1 919 668 8900, Fax: +1 919 668 7056, Email: christopher.granger{at}duke.edu
Aims: To assess the incidence and timing of atrial fibrillation (AF), describe antithrombotic therapy use, and evaluate the association of AF with 90 day mortality and other secondary clinical outcomes.
Methods and results: We studied 5745 ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention (PCI) in APEX-AMI. Approximately 11% had AF during hospitalization. Atrial fibrillation prevalence at baseline and at discharge was 4.8% [confidence interval (CI) 4.3–5.4%] and 2.5% (CI 2.1–2.9%), respectively. The proportion of 5466 patients without AF at baseline who developed new onset AF was 6.3% (CI 5.6–6.9%). This corresponded to 9.3 cases of new onset AF/1000 patient days at risk. New onset AF was independently associated with 90 day mortality [adjusted hazard ratio (HR) 1.81; 95% CI 1.06–3.09; P = 0.029] after accounting for baseline covariates and in-hospital procedures and complications. New onset AF was associated with shock (adjusted HR 3.81; 95% CI 1.88–7.70; P = 0.0002), congestive heart failure (adjusted HR 2.66; 95% CI 1.74–4.06; P < 0.0001), and stroke (adjusted HR 2.98; 95% CI 1.47–6.04; P = 0.0024) in models accounting for baseline covariates. Of AF patients, 55% did not receive oral anticoagulation therapy at discharge. Among patients with coronary stents, 5.1% were discharged on triple therapy. Patients at highest risk of stroke (CHADS2 score 
2) were least likely to receive oral anticoagulation at discharge (39%). Warfarin use in patients with AF at discharge (43.4%) was associated with lower rates of 90 day mortality and stroke.
Conclusion: Atrial fibrillation prevalence at baseline and at discharge was 4.8 and 2.5%, respectively. The proportion of patients 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 patients undergoing primary PCI.
Key Words: Atrial fibrillation • Myocardial infarction • Antithrombotic therapy • Outcomes