Preprocedural AF associated with poor outcomes post PCI

Hospital in-patients with preprocedural atrial fibrillation (AF) may be higher-risk for complications post percutaneous coronary intervention (PCI), Australian cardiologists warn.

A study of 13,286 consecutive procedures found in-hospital and long-term mortality rates were four and three-times higher in patients with AF pre-PCI than those with sinus rhythm, respectively (11% vs 3%, P < 0.001 and 31% versus 10%, adjusted hazard ratio: 1.38, P < 0.001).

AF patients also had higher rates of in-hospital major bleeding and major adverse cardiovascular events, including a composite of all-cause mortality, myocardial infarction and target vessel revascularisation (3% vs 1% P < 0.001 and 12% versus 4%, P < 0.001), Dr Riley Batchelor, Royal Melbourne Hospital cardiology registrar and his team wrote in Heart, Lung and Circulation.

AF is “common among patients presenting for PCI” and warrants careful consideration during the preprocedure risk-assessment, the authors wrote.

The phenomenon has been seen in up to 10% of patients presenting for PCI and puts them at risk of developing or worsening heart failure, type II myocardial infarction and, potentially, extra PCI procedures.

“Rapid heart rate increases myocardial oxygen demand and may lead to an impairment in coronary perfusion, resulting in type II [myocardial infarction], especially in those with preexisting coronary artery disease, with possible progression and exposure to risks of additional PCI procedures,” the authors explained.

“Even after adjustment for pre-existing cardiovascular disease, AF alone is associated with a 1.5–1.9-fold mortality risk increase”, they wrote.

The link between AF and mortality was likely multifactorial, with major bleeding, preprocedural anticoagulant and antiplatelet medications and the indication for PCI known contributors. Additionally, AF patients were typically older and more likely to have comorbidities such as diabetes, hypertension and moderate-to-severe left ventricular systolic dysfunction, they found.

This risk-factor stew posed a “clinical dilemma” for physicians, where the dual antiplatelet therapy and oral anticoagulant needed to prevent cardiac and cerebrovascular ischaemic events in pre-PCI AF patients significantly increased the chance of major bleeding. Direct oral anticoagulants may be a partial solution, demonstrating reduced bleeding major bleeding risk in AF versus oral warfarin while maintaining non-inferiority in stroke prevention, the authors suggested.

“In contemporary Australian practice, oral anticoagulation is continued long-term in patients undergoing PCI, but the choice of the number of antiplatelet agents (whether dual or single) and duration of antiplatelet therapy varies contingent on the perceived thrombotic and bleeding risk factors,” they noted.

Preprocedural AF should factor into treatment decisions, given its impact on short- and long-term outcomes post PCI, Dr Batchelor and his team recommended.

“The combination and consistency of [our]  findings suggest that AF is a marker for a high-risk patient group at significant risk of in-hospital complications of PCI.”

Further, “the consistent trend in poor long-term outcomes [seen in this and other studies] underscores the vulnerability of patients with AF characterised by less biologic reserve, subject to the complications of various chronic illnesses, and consequently exposed to greater competing mortality risk of comorbid conditions.”

“These findings should be weighted and considered carefully when evaluating patients with AF who require PCI,” the authors concluded.

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