The Status Of Antithrombotic Management For Acute Coronary Syndrome Concomitant With Atrial Fibrillation

Aim:The optimal antithrombotic strategy in Coronary Artery Disease(CAD)patients concomitant with Arial Fibrillation(AF)is controversial.However,the actual consequence of antithrombotic management in these patients is unclear in China.Our study was to investigate the prevalence of antithrombotic strategy and clinical prognosis in CAD patients concomitant with AF.MethodsWe performed a retrospective study and the data were collected in the databases of Zhengzhou University People’s Hospital in China.Patients who met the inclusion criteria and discharged during January 1,2012 to June 30,2016 were enrolled.All patients were followed up at least 1 year via telephone.A total of 1052 patients discharged with ACS complicated with AF were selected.The group of triple antithrombotic therapy(AP+AP+OAC,n=131)accounted for 8.7%,dual antiplatelet group(AP+AP,n=494)accounted for 32.9%,and 13.0% of patients used single antiplatelet combined single oral anticoagulant therapy(AP+OAC,n=195).In AP+AP group.Quantitative data and qualitative data were statistically analyzed using t-test and χ2 test,respectively.Logistic regression was used to assess the factors associated with oral anticoagulant use.Kaplan-Meier test evaluated the survival rate of patients under different antithrombotic treatment methods.Cox proportional hazard model was applied to estimate the risk of outcome associated with antithrombotic therapy.Results:1.There was no statistical difference between male and female in the three treatment groups In the AP+AP group,AP+OAC group and AP+AP+OAC group,patients with age ≥75 years accounted for 40.9%,28.7% 和 and 21.4%,respectively(P=0.003);patients with CHA2DS2-VASc score ≥ 2 accounted for 85.6%,94.9% and 91.6%,respectively(P=0.001);patients with HAS-BLED score <3 accounted for 65.6%,84.1% and 81.7%,respectively(P=0.001).2.During followed up(34±13 months),54.96% and 43.59% of patients were treated with a single anticoagulant therapy after one year,who have been hospitalized with AP+AP+OAC therapy and AP+OAC therapy respectively.Less than 50% of the patients had an INR of between 2 to 3.Among Patients who have been hospitalized with AP+AP therapy,87.93% received single antiplatelet therapy after one year.3.Correlation analysis of factors affecting the use of OAC was performed on patients with an absolute indication of OAC(CHADS2-VASc score ≥ 2).OAC use was negatively correlated with age ≥ 75 years(OR,0.47;95%CI,[0.35-0.53];P <0.001),acute coronary syndrome(OR,0.80;95%CI,[0.64-1.00];P =0.05),and previous bleeding history(OR,2.11;95%CI,[1.07-4.16];P =0.031);however,it was positively correlated BMI ≥ 24(OR,1.34;95%CI 为[1.08-1.66];P =0.008),history of heart failure(OR,1.38,95%CI,[1.12-1.69];P =0.002),previous history of cerebral infarction(OR,0.73;95%CI,[0.58-0.90];P = 0.004),and conversion of sinus rhythm(OR,1.59,95%CI,[1.26-1.99];P <0.001).4.The incidence of embolic events(AP+AP VS.AP+OAC VS.AP+AP+OAC,5.0% VS.1.0% VS.0.8%,P=0.05)and acute myocardial infarction events(AP+AP VS.AP+OAC VS.AP+AP+OAC,0.4% VS.0.5% VS.0.8%,P=0.87)in the group of AP+AP+OAC therapy was the lowest,but it had a higher risk of hemorrhage(AP+AP VS.AP+OAC VS.AP+AP+OAC,2.8% VS.2.6% VS.5.3%,P=0.05)..However,there was no statistical difference for embolic events between AP+OAC group and AP+AP+OAC group(AP+OAC VS.AP+AP+OAC,1.0% VS.0.8%,P=0.65).The incidence of acute myocardial infarction in AP+OAC group was similar to AP+AP group(AP+AP VS.AP+OAC,0.4% VS.0.5%,P=0.87).5.Multivariate COX analysis showed that history of cerebral infarction(RR,95%CI:0.51[0.27-0.81],p = 0.004)and the use of warfarin(RR,95%CI:0.27[0.83-0.93],p = 0.037)reduced the incidence of ischemic stroke events;age ≥ 75 years(RR,95%CI:2.04[1.24-3.34],p = 0.005)increased the occurrence of embolic events.History of bleeding(RR,95% CI: 0.15 [0.05-0.45],p = 0.001)reduced the occurrence of bleeding events but it increased the acute myocardial infarction events rates(RR,95% CI: 2.59 [1.33-5.87],p = 0.019).Conclusions:1.Among patients discharged with ACS complicated with AF,The group of triple antithrombotic therapy(AP+AP+OAC)accounted for 8.7%,dual antiplatelet group(AP+AP)accounted for 32.9%,and 13.0% of patients used single antiplatelet combined single oral anticoagulant therapy(AP+OAC).2.Patients with AP+AP+OAC therapy and AP+OAC therapy had 54.96% and 43.59% treated with a single anticoagulant therapy after one year.Among Patients who have been hospitalized with AP+AP therapy,87.93% received single antiplatelet therapy after one year.3.Correlation analysis of factors affecting the use of OAC was performed on patients with an absolute indication of OAC(CHADS2-VASc score ≥ 2).OAC use was negatively correlated with age ≥ 75 years,acute coronary syndrome,and previous bleeding history;and it was positively correlated BMI ≥ 24,history of heart failure,previous history of cerebral infarction,and conversion of sinus rhythm.4.There was no statistical difference in the incidence of embolism events between AP+OAC group and AP+AP+OAC group,but the incidence of bleeding events was significantly lower than that AP+AP+OAC group.There was no significant difference in the incidence of myocardial infarction events between the AP+OAC group and the AP+AP group.5.Multivariate analysis of events indicated that the history of cerebral infarction and the use of warfarin decrease the occurrence of ischemic stroke;and age was a risk factor for ischemic stroke but not a risk factor for bleeding.