Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Arrhythmia Center, Department of Cardiology, St. Francis Hospital, Roslyn, New York.
Clinical Trials Center, Cardiovascular Research Foundation, New York, New York.
J Am Coll Cardiol. 2018 Feb 20;71(7):739-748. doi: 10.1016/j.jacc.2017.12.012.
There is limited information on the incidence and prognostic impact of new-onset atrial fibrillation (NOAF) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD).
This study sought to determine the incidence of NOAF following PCI and CABG for LMCAD and its effect on 3-year cardiovascular outcomes.
In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. Outcomes were analyzed according to the development of NOAF during the initial hospitalization following revascularization.
Among 1,812 patients without atrial fibrillation on presentation, NOAF developed at a mean of 2.7 ± 2.5 days after revascularization in 162 patients (8.9%), including 161 of 893 (18.0%) CABG-treated patients and 1 of 919 (0.1%) PCI-treated patients (p < 0.0001). Older age, greater body mass index, and reduced left ventricular ejection fraction were independent predictors of NOAF in patients undergoing CABG. Patients with versus without NOAF had a significantly longer duration of hospitalization, were more likely to be discharged on anticoagulant therapy, and had an increased 30-day rate of Thrombolysis In Myocardial Infarction major or minor bleeding (14.2% vs. 5.5%; p < 0.0001). By multivariable analysis, NOAF after CABG was an independent predictor of 3-year stroke (6.6% vs. 2.4%; adjusted hazard ratio [HR]: 4.19; 95% confidence interval [CI]: 1.74 to 10.11; p = 0.001), death (11.4% vs. 4.3%; adjusted HR: 3.02; 95% CI: 1.60 to 5.70; p = 0.0006), and the primary composite endpoint of death, MI, or stroke (22.6% vs. 12.8%; adjusted HR: 2.13; 95% CI: 1.39 to 3.25; p = 0.0004).
In patients with LMCAD undergoing revascularization in the EXCEL trial, NOAF was common after CABG but extremely rare after PCI. The development of NOAF was strongly associated with subsequent death and stroke in CABG-treated patients. Further studies are warranted to determine whether prophylactic strategies to prevent or treat atrial fibrillation may improve prognosis in patients with LMCAD who are undergoing CABG. (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776).
左主干冠状动脉疾病（LMCAD）行经皮冠状动脉介入治疗（PCI）和冠状动脉旁路移植术（CABG）后新发心房颤动（NOAF）的发生率和预后影响的相关信息有限。
本研究旨在确定 LMCAD 行经 PCI 和 CABG 后新发心房颤动的发生率及其对 3 年心血管结局的影响。
在 EXCEL（依维莫司洗脱支架 PCI 与冠状动脉旁路移植术治疗左主干血运重建效果比较）试验中，1905 例 LMCAD 且 SYNTAX 评分低或中度的患者被随机分为 PCI 组（使用依维莫司洗脱支架）和 CABG 组。根据再血管化后住院期间新发 NOAF 的情况对结果进行分析。
在 1812 例入院时无房颤的患者中，162 例（8.9%）患者于再血管化后平均 2.7±2.5 天发生 NOAF，包括 893 例 CABG 治疗患者中的 161 例（18.0%）和 919 例 PCI 治疗患者中的 1 例（0.1%）（p<0.0001）。年龄较大、体重指数较高和左心室射血分数降低是 CABG 患者发生 NOAF 的独立预测因素。发生与未发生 NOAF 的患者住院时间更长，更有可能接受抗凝治疗出院，且 30 天内发生心肌梗死大出血或小出血的发生率更高（14.2% vs. 5.5%；p<0.0001）。多变量分析显示，CABG 后新发心房颤动是 3 年卒中（6.6% vs. 2.4%；调整后危险比[HR]：4.19；95%置信区间[CI]：1.74 至 10.11；p=0.001）、死亡（11.4% vs. 4.3%；调整后 HR：3.02；95% CI：1.60 至 5.70；p=0.0006）和死亡、心肌梗死或卒中主要复合终点（22.6% vs. 12.8%；调整后 HR：2.13；95% CI：1.39 至 3.25；p=0.0004）的独立预测因素。
在 EXCEL 试验中接受再血管化治疗的 LMCAD 患者中，CABG 后新发心房颤动很常见，但 PCI 后非常罕见。NOAF 的发生与 CABG 治疗患者随后的死亡和卒中强烈相关。需要进一步研究以确定预防或治疗心房颤动的策略是否可能改善接受 CABG 治疗的 LMCAD 患者的预后。（依维莫司洗脱支架 PCI 与冠状动脉旁路移植术治疗左主干血运重建效果比较[EXCEL]；NCT01205776）。
