Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
JACC Cardiovasc Interv. 2017 Jun 12;10(11):1075-1085. doi: 10.1016/j.jcin.2017.02.028. Epub 2017 May 17.
This study sought to investigate the incidence, management, and clinical relevance of atrial fibrillation (AF) during and after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and evaluate outcomes of different antithrombotic strategies.
Uncertainty exists regarding the optimal antithrombotic strategy in patients with AF who are undergoing PCI with DES.
Using a consecutive series of 10,027 patients who underwent DES implantation between 2003 and 2011, we evaluated the overall prevalence and clinical impact of AF. In addition, we compared the efficacy and safety of dual antiplatelet therapy (DAPT) (aspirin plus clopidogrel) and triple therapy (DAPT plus warfarin) among patients with AF. The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke.
Overall, 711 (7.1%) patients had a diagnosis of AF at the index PCI. Patients with AF were older, had more comorbid conditions, and more often had a history of strokes; most patients with AF (88.4%) received DAPT rather than triple therapy (10.5%) at discharge. The rate of primary outcome after PCI during the 6-year follow-up period was significantly higher in patients with AF than in those without AF (22.1% vs. 8.0%; p < 0.001). This trend was consistent for major bleeding (4.5% vs. 1.5%; p < 0.001). After multivariable adjustment, the presence of AF was significantly associated with a higher risk of primary outcome (hazard ratio [HR]: 2.33; 95% confidence interval [CI]: 1.95 to 2.79; p < 0.001) and major bleeding (HR: 2.01; 95% CI: 1.32 to 3.06; p = 0.001). Among patients with AF, adjusted risk for the primary outcome was similar between the DAPT group and the triple therapy group (HR: 1.01; 95% CI: 0.60 to 1.69; p = 0.98), but triple therapy was associated with a significantly higher risk of hemorrhagic stroke (HR: 7.73; 95% CI: 2.14 to 27.91; p = 0.002) and major bleeding (HR: 4.48; 95% CI: 1.81 to 11.08; p = 0.001).
Among patients receiving DES implantation, AF was not rare and was associated with increased ischemic and bleeding risk. In patients with AF, triple therapy was not associated with decreased ischemic events but was associated with increased bleeding risk compared to DAPT.
本研究旨在探讨经皮冠状动脉介入治疗（PCI）中药物洗脱支架（DES）植入后心房颤动（AF）的发生率、处理方法和临床相关性，并评估不同抗栓策略的结果。
在接受 DES 植入的 AF 患者中，最佳抗栓策略仍存在不确定性。
我们连续纳入了 2003 年至 2011 年间接受 DES 植入的 10027 例患者，评估了 AF 的总体患病率和临床影响。此外，我们比较了 AF 患者中双联抗血小板治疗（DAPT）（阿司匹林加氯吡格雷）和三联治疗（DAPT 加华法林）的疗效和安全性。主要结局是心血管死亡、心肌梗死或卒中的复合事件。
总体而言，711 例（7.1%）患者在指数 PCI 时诊断为 AF。AF 患者年龄较大，合并症较多，且更常发生卒中史；大多数 AF 患者（88.4%）在出院时接受 DAPT 治疗，而非三联治疗（10.5%）。在 6 年的随访期间，AF 患者的主要结局发生率明显高于无 AF 患者（22.1% vs. 8.0%；p<0.001）。主要出血事件（4.5% vs. 1.5%；p<0.001）也存在同样趋势。多变量调整后，AF 的存在与主要结局风险显著相关（风险比[HR]：2.33；95%置信区间[CI]：1.95 至 2.79；p<0.001）和主要出血风险（HR：2.01；95% CI：1.32 至 3.06；p=0.001）。在 AF 患者中，DAPT 组和三联治疗组的主要结局风险调整后相似（HR：1.01；95% CI：0.60 至 1.69；p=0.98），但三联治疗与出血性卒中（HR：7.73；95% CI：2.14 至 27.91；p=0.002）和主要出血事件（HR：4.48；95% CI：1.81 至 11.08；p=0.001）风险显著增加相关。
在接受 DES 植入的患者中，AF 并不少见，与缺血性和出血性风险增加相关。在 AF 患者中，三联治疗并未降低缺血事件风险，反而与出血风险增加相关，而与 DAPT 相比。
