Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
J Am Heart Assoc. 2017 Aug 21;6(8):e005280. doi: 10.1161/JAHA.116.005280.
Patients receiving oral anticoagulation in addition to dual-antiplatelet therapy are known to be at high risk for bleeding events; thus, the selection of a drug-eluting stent (DES) versus a bare metal stent (BMS) can have important implications for patients with atrial fibrillation (AF) presenting with acute myocardial infarction (MI).
From the National Cardiovascular Data Registry ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines, we identified 14 427 AF patients presenting with acute MI undergoing percutaneous coronary intervention from 2008 to 2014. Temporal trends and hospital variation in DES use were examined, as were patterns of use by stroke risk (CHADS-VASc) and bleeding risk ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation). Among patients with linked Medicare data (n=2844), multivariable Cox regression modeling was used to compare risks for a composite outcome (all-cause mortality, readmission for stroke, or MI), readmission for stroke, revascularization, and major bleeding at 1 year. A DES was used in 8414 (58.9%) MI patients with AF, increasing from 47.1% in 2008 to 67.9% in 2014, with wide variation among hospitals. DES placement was more common than BMS placement among patients at high stroke risk (CHADS-VASc ≥2) and high bleeding risk (ATRIA ≥4). Although aspirin and a P2Y inhibitor were prescribed for >95% of all patients regardless of stent type at discharge, warfarin was prescribed less frequently among patients receiving a DES than a BMS (31% versus 39%, <0.001). The composite outcome was similar between patients with a DES or BMS at 1 year (22% versus 26%; adjusted hazard ratio: 0.88; 95% confidence interval [CI], 0.76-1.03).
Use of DESs among MI patients with AF has increased over time, but substantial hospital-level variation was observed. Patients with AF meeting indications for anticoagulation are more likely to receive a DES than a BMS, even among those at high predicted risk of both stroke and bleeding.
已知同时接受口服抗凝和双联抗血小板治疗的患者发生出血事件的风险较高；因此，对于伴有房颤（AF）的急性心肌梗死（MI）患者，选择药物洗脱支架（DES）还是裸金属支架（BMS）可能会对患者产生重要影响。
从 2008 年至 2014 年，我们从全国心血管数据注册机构 ACTION（急性冠状动脉治疗和干预结果网络）注册库-GET WITH THE GUIDELINES 中确定了 14427 例接受经皮冠状动脉介入治疗的伴有急性 MI 的 AF 患者。我们检查了 DES 使用的时间趋势和医院差异，以及根据卒中风险（CHADS-VASc）和出血风险 ATRIA（抗凝和房颤中的危险因素）的使用模式。在具有 Medicare 相关数据的患者中（n=2844），使用多变量 Cox 回归模型比较了复合结局（全因死亡率、卒中再入院或 MI）、卒中再入院、血运重建和 1 年时大出血的风险。在 8414 例伴有 AF 的 MI 患者中使用了 DES，从 2008 年的 47.1%增加到 2014 年的 67.9%，各医院之间存在很大差异。DES 放置在高卒中风险（CHADS-VASc≥2）和高出血风险（ATRIA≥4）的患者中比 BMS 更常见。尽管阿司匹林和 P2Y 抑制剂在出院时为>95%的所有患者开具处方，无论支架类型如何，但与 BMS 相比，DES 治疗的患者开具华法林的频率较低（31%与 39%，<0.001）。DES 或 BMS 治疗的患者在 1 年时的复合结局相似（22%与 26%；调整后的危害比：0.88；95%置信区间[CI]：0.76-1.03）。
随着时间的推移，MI 合并 AF 患者中使用 DES 的比例有所增加，但观察到了很大的医院间差异。符合抗凝指征的 AF 患者更有可能接受 DES 而不是 BMS，即使是在那些卒中风险和出血风险均较高的患者中。
