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Published on: February 26, 2013
Atrial fibrillation and acute myocardial infarction: antithrombotic therapy and outcomes
Renato D Lopes1, Li Li, Christopher B Granger
1Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA. renato.lopes@duke.edu
Insights
Warfarin use increased with higher stroke and bleeding risks in myocardial infarction patients with atrial fibrillation. However, less than half received warfarin at discharge, indicating a need for clearer antithrombotic therapy guidelines.
Area of Science:
- Cardiology
- Clinical Medicine
- Pharmacology
Background:
- Atrial fibrillation guidelines recommend long-term warfarin for stroke risk.
- Combining warfarin with antiplatelet therapy after myocardial infarction presents challenges.
Purpose of the Study:
- To describe antithrombotic therapy use in acute myocardial infarction patients with atrial fibrillation.
- To analyze outcomes based on stroke and bleeding risk stratification.
Main Methods:
- Retrospective analysis of 69,255 patients from the National Cardiovascular Data Registry (July 2008-September 2009).
- Focus on 4,947 patients with atrial fibrillation diagnosed within two weeks of myocardial infarction.
- Description of discharge antithrombotic therapy across risk levels.
Main Results:
- Patients with atrial fibrillation were older, had more comorbidities, and worse in-hospital outcomes.
- Warfarin use at discharge increased with higher CHADS(2) stroke risk scores and bleeding risk.
- Triple therapy (aspirin, clopidogrel, warfarin) was used in only 14.6% of this population.
Conclusions:
- Warfarin use at discharge is higher in patients with elevated stroke and bleeding risks but remains underutilized.
- Less than half of high-risk patients received warfarin, highlighting a gap in treatment.
- Clarification of antithrombotic therapy guidelines is needed for patients with concurrent atrial fibrillation and acute myocardial infarction.
Background:
Atrial fibrillation guidelines recommend long-term use of warfarin according to a patient's predicted risk of stroke. After acute myocardial infarction, however, combining warfarin and antiplatelet medications poses challenges.
Methods:
By using data from more than 69,255 patients with acute myocardial infarction who were enrolled in the National Cardiovascular Data Registry's Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines at 309 hospitals from July 1, 2008, to September 30, 2009, we describe the characteristics and outcomes of the population with myocardial infarction with atrial fibrillation diagnosed within 2 weeks before index myocardial infarction admission (7.1%, N=4947). Use of discharge antithrombotic therapy is described overall and across levels of predicted stroke and bleeding risks.
Results:
Compared with patients without atrial fibrillation, those with atrial fibrillation before their index myocardial infarction were older and had more comorbidities and worse in-hospital outcomes. Only 32.5% of patients with atrial fibrillation were taking warfarin before their myocardial infarction admission. In these patients, use of warfarin at discharge increased with higher Congestive heart failure, Hypertension, Age, Diabetes, Stroke [Doubled] (CHADS(2)) risk strata (28.5%, 34.6%, and 43.5% for CHADS(2) scores 0, 1, and ≥2; P<.001) and increased in patients at low, intermediate, and high risk of bleeding (25.4%, 42.3%, and 42.1%; P=.004). Triple therapy at discharge (aspirin plus clopidogrel plus warfarin) was used in a minority of this population (14.6%).
Conclusions:
Use of warfarin at discharge in patients with atrial fibrillation is greater among those with higher stroke and bleeding risks, but despite higher-risk profiles, less than half received warfarin at discharge. These findings highlight that clarification is needed to guide choice of antithrombotic therapy for patients with both atrial fibrillation and acute myocardial infarction.
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