Jackson Larry R, Piccini Jonathan P, Cyr Derek D, Roe Matthew T, Neely Megan L, Martinez Felipe, Lüscher Thomas F, Lopes Renato D, Winters Kenneth J, White Harvey D, Armstrong Paul W, Fox Keith A A, Prabhakaran Dorairaj, Bhatt Deepak L, Magnus Ohman E, Corbalán Ramón
Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Duke Clinical Research Institute, Durham, North Carolina.
Clin Cardiol. 2016 Sep;39(9):497-506. doi: 10.1002/clc.22562. Epub 2016 Jul 28.
Associations between atrial fibrillation (AF), outcomes, and response to antiplatelet therapies in patients with acute coronary syndrome (ACS) managed medically without revascularization remain uncertain. We examined these associations for medically managed ACS patients randomized to dual antiplatelet therapy (DAPT) using patient data from the TRILOGY ACS trial. DAPT included aspirin plus clopidogrel 75 mg/d or prasugrel 10 mg/d (5 mg/d for those <60 kg or age ≥75 years). Patients receiving oral anticoagulants were excluded. Cox proportional hazards regression modeling was used to characterize associations between patients with AF (AF+) vs those without (AF-) and risk of ischemic and bleeding events, and to explore effects of randomized treatment on outcomes. Among 9101 patients with baseline AF status, 710 (7.8%) had AF. AF+ patients were older and had more comorbidities. Unadjusted associations of the composite of cardiovascular death/myocardial infarction/stroke were significantly higher among AF patients at 30 months (31.1% vs 18.4%; HR: 1.61, 95% CI: 1.35-1.92, P < 0.001), but differences did not persist after adjustment (HR: 1.16, 95% CI: 0.97-1.39, P = 0.11). When individual components of the composite endpoint were evaluated, 30-month risk of events in AF+ patients was significantly higher. Thirty-month risk of all-cause death was significantly higher in AF+ patients: 18.1% vs 11.1% (HR: 1.62, 95% CI: 1.30-2.02, P < 0.001). There was no significant interaction with randomized treatment and AF for the primary endpoint. Among medically managed high-risk ACS patients receiving DAPT, AF was associated with higher unadjusted risks of ischemic and bleeding outcomes that were similar by treatment group.
在未经血运重建而接受药物治疗的急性冠状动脉综合征（ACS）患者中，心房颤动（AF）、预后以及对抗血小板治疗的反应之间的关联仍不明确。我们利用TRILOGY ACS试验的患者数据，对随机接受双联抗血小板治疗（DAPT）的药物治疗ACS患者的这些关联进行了研究。DAPT包括阿司匹林加氯吡格雷75 mg/天或普拉格雷10 mg/天（体重<60 kg或年龄≥75岁者为5 mg/天）。排除接受口服抗凝剂的患者。采用Cox比例风险回归模型来描述AF患者（AF+）与非AF患者（AF-）之间的关联以及缺血和出血事件的风险，并探讨随机治疗对预后的影响。在9101例有基线AF状态的患者中，710例（7.8%）有AF。AF+患者年龄更大，合并症更多。在30个月时，AF患者中心血管死亡/心肌梗死/卒中复合终点的未调整关联显著更高（31.1%对18.4%；HR：1.61，95%CI：1.35 - 1.92，P<0.001），但调整后差异未持续存在（HR：1.16，95%CI：0.97 - 1.39，P = 0.11）。当评估复合终点的各个组成部分时，AF+患者30个月的事件风险显著更高。AF+患者30个月的全因死亡风险显著更高：18.1%对11.1%（HR：1.62，95%CI：1.30 - 2.02，P<0.001）。对于主要终点，随机治疗与AF之间无显著交互作用。在接受DAPT的药物治疗的高危ACS患者中，AF与更高的未调整缺血和出血结局风险相关，各治疗组情况相似。
