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Outcomes and Prognostic Impact of Prophylactic Oral Anticoagulation in Anterior ST-Segment Elevation Myocardial
Jay S Shavadia1,2,3, Erik Youngson1,4, Kevin R Bainey1,2
1University of Alberta, Edmonton, Alberta, Canada.
Insights
Prophylactic warfarin in anterior ST-segment myocardial infarction (STEMI) with left ventricle dysfunction did not improve ischemic outcomes. However, it was associated with reduced mortality but increased bleeding risk in high-risk STEMI patients.
Area of Science:
- Cardiology
- Internal Medicine
- Clinical Research
Background:
- The use of prophylactic anticoagulation after anterior ST-segment myocardial infarction (STEMI) with left ventricle dysfunction remains controversial.
- Left ventricle dysfunction (LVEF ≤40%) identifies high-risk STEMI patients.
- Current guidelines lack clarity on anticoagulation for this specific patient group.
Purpose of the Study:
- To evaluate the contemporary role of prophylactic warfarin in high-risk anterior STEMI patients.
- To assess the impact of warfarin on ischemic events, thromboembolism, and mortality.
- To determine the association between warfarin use and bleeding complications.
Main Methods:
- Retrospective analysis of 2032 STEMI admissions.
- Inclusion of high-risk patients (anterior STEMI, LVEF ≤40%), excluding those with atrial fibrillation or existing left ventricle thrombus.
- Primary outcome: adjusted 1-year composite of recurrent ischemia, stroke/TIA/systemic embolism, or all-cause death, compared between warfarin users and non-users.
Main Results:
- Of 436 high-risk patients, 59.3% received prophylactic warfarin.
- Warfarin use was not associated with a reduced adjusted ischemic composite (OR 0.96) or thromboembolic events (OR 1.99).
- A significant reduction in 1-year all-cause mortality (OR 0.30) was observed, alongside a numerical increase in major bleeding (OR 2.17).
Conclusions:
- Prophylactic warfarin in high-risk anterior STEMI patients does not improve ischemic outcomes.
- The observed reduction in mortality with warfarin use warrants further investigation, balanced against an increased bleeding risk.
- Further research is needed to clarify the optimal anticoagulation strategy in this population.
Background:
The contemporary role of prophylactic anticoagulation following extensive anterior wall ST-segment myocardial infarction (STEMI) is unclear.
Methods And Results:
We evaluated anterior STEMI patients with left ventricle dysfunction (left ventricular ejection fraction ≤40%) ("high risk"), categorized by prophylactic warfarin use, within a regional STEMI. Patients with pre-existing atrial fibrillation were excluded. The primary outcome was an adjusted (for Global Registry of Acute Coronary Events risk score) 1-year composite of recurrent ischemia, stroke/transient ischemic attack/systemic embolism, or all-cause death. Of the 2032 STEMI admissions, 436 (21.5%) were high risk. After excluding 19 (4.4%) patients with definite left ventricle thrombus and 21 (4.8%) in-hospital deaths (2 had left ventricle thrombus), prophylactic warfarin was utilized in 236/398 (59.3%) high-risk survivors. Prescriptions were comparable across sex, but recipients were on average younger (58.5 years versus 64.0 years, P<0.001) and lower risk (Global Registry of Acute Coronary Events risk: 163 versus 181, P<0.001). No association on the adjusted ischemic composite (23.3% versus 25.3%, odds ratio 0.96, 95% CI 0.60-1.55) or thromboembolic events (2.1% versus 1.2%, odds ratio 1.99, 95% CI 0.38-10.51) was observed, but reduced 1-year all-cause mortality was noted (2.5% versus 8.6%, odds ratio 0.30, 95% CI 0.11-0.81); numerically higher major bleeding was observed at 1 year (2.5% versus 1.2%, odds ratio 2.17, 95% CI 0.43-10.96).
Conclusions:
A high utilization of prophylactic warfarin occurs in anterior STEMI patients with left ventricle dysfunction, yet appears to provide no additional benefit on the ischemic composite. The association with lower all-cause mortality, but higher bleeding, calls for an improved understanding of its role in high-risk STEMI.
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