Outcomes in Newly Diagnosed Atrial Fibrillation and History of Acute Coronary Syndromes: Insights from GARFIELD-AF

Freek W.A. Verheugt, Giuseppe Ambrosio, Dan Atar, Jean-Pierre Bassand, A. John Camm, Juan Pablo Costabel, David A. Fitzmaurice, Laura Illingworth, Samuel Z. Goldhaber, Shinya Goto, Sylvia Haas, Petr Jansky, Gloria Kayani, Janina Stepinska, Alexander G.G. Turpie, Martin van Eickels, Ajay K. Kakkar
The American Journal of Medicine. 2019-12-01; 132(12): 1431-1440.e7
DOI: 10.1016/J.AMJMED.2019.06.008

PubMed
Read on PubMed



1. Am J Med. 2019 Dec;132(12):1431-1440.e7. doi: 10.1016/j.amjmed.2019.06.008. Epub
2019 Jul 12.

Outcomes in Newly Diagnosed Atrial Fibrillation and History of Acute Coronary
Syndromes: Insights from GARFIELD-AF.

Verheugt FWA(1), Ambrosio G(2), Atar D(3), Bassand JP(4), Camm AJ(5), Costabel
JP(6), Fitzmaurice DA(7), Illingworth L(8), Goldhaber SZ(9), Goto S(10), Haas
S(11), Jansky P(12), Kayani G(8), Stepinska J(13), Turpie AGG(14), van Eickels
M(15), Kakkar AK(16); GARFIELD-AF Investigators.

Author information:
(1)Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The
Netherlands. Electronic address: .
(2)Division of Cardiology, University of Perugia School of Medicine, Perugia,
Italy.
(3)Department of Cardiology, Oslo University Hospital Ullevål and University of
Oslo, Norway.
(4)Department of Cardiology, University of Besançon, Besançon, France; Department
of Clinical Research, Thrombosis Research Institute, London, United Kingdom.
(5)Department of Cardiology, St. George’s University of London, United Kingdom.
(6)Cardiovascular Emergency Care Section, Instituto Cardiovascular de Buenos
Aires, Argentina.
(7)WMS – Warwick Clinical Trials Unit, University of Warwick, Coventry, United
Kingdom.
(8)Department of Clinical Research, Thrombosis Research Institute, London, United
Kingdom.
(9)Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical
School, Boston, Massachusetts, United States of America.
(10)Department of Medicine (Cardiology), Tokai University School of Medicine,
Kanagawa, Japan.
(11)Formerly Haemostasis and Thrombosis Research Group, Technical University of
Munich, Germany.
(12)Cardiovascular Center, University Hospital Motol, Prague, Czech Republic.
(13)Department of Intensive Cardiac Therapy, Institute of Cardiology, Warsaw,
Poland.
(14)Department of Medicine, McMaster University, Hamilton, Ontario,Canada.
(15)Bayer AG, Berlin, Germany.
(16)Department of Clinical Research, Thrombosis Research Institute, London,
United Kingdom; Department of Surgery, University College London, United Kingdom.

BACKGROUND: Many patients with atrial fibrillation have concomitant coronary
artery disease with or without acute coronary syndromes and are in need of
additional antithrombotic therapy. There are few data on the long-term clinical
outcome of atrial fibrillation patients with a history of acute coronary
syndrome. This is a 2-year study of atrial fibrillation patients with or without
a history of acute coronary syndromes.
METHODS: Adults with newly diagnosed atrial fibrillation and ≥1
investigator-defined stroke risk factor were enrolled in GARFIELD-AF between
March 2010 and September 2015. The association between prior acute coronary
syndromes and long-term outcomes was determined using a Cox proportional hazards
model, adjusting for baseline risk factors, oral anticoagulation (OAC) ±
antiplatelet (AP) therapy, and usual care.
RESULTS: Of 39,679 patients, 10.5% had a history of acute coronary syndromes. At
2-year follow-up, patients with prior acute coronary syndromes had higher
adjusted risks of stroke/systemic embolism (hazard ratio [HR] 1.39; 95%
confidence interval [CI], 1.08-1.78), major bleeding (HR 1.30; 95% CI, 0.95
-1.79), all-cause mortality (HR 1.34; 95% CI, 1.21 -1.49), cardiovascular
mortality (HR 1.85; 95% CI, 1.51-2.26), and new acute coronary syndromes (HR
3.42; 95% CI, 2.62-4.45). Comparing antithrombotic therapy in the acute coronary
syndromes vs no acute coronary syndromes groups, most patients received OAC ± AP:
60.8% vs 66.1%, but AP therapy was more likely in the acute coronary syndromes
group (68.1% vs 32.9%), either alone (34.9% vs 20.8%) or with OAC (33.2% vs
12.1%). Overall, 17.8% in the acute coronary syndromes group received dual AP
therapy with (5.3%) or without OAC (12.5%). Among patients with moderate/high
risk for stroke/systemic embolism, fewer in the acute coronary syndromes group
received OAC with or without AP therapy (Congestive heart failure, Hypertension,
Age 75 years, Diabetes mellitus, prior Stroke, TIA, or thromboembolism, Vascular
disease, Age 65-74 years, Sex category [CHA2DS2-VASc] 2: 52.1% vs 64.6%;
CHA2DS2-VASc ≥3: 62.0% vs 70.7%), and the majority with a Hypertension
(uncontrolled systolic blood pressure >160 mm Hg), Abnormal renal or liver
function, previous Stroke, Bleeding history or predisposition, Labile
international normalized ratios, Elderly, and concomitant Drugs or alcohol excess
(HAS-BLED) score ≥3 were on AP therapy (83.8% vs 65.5%).
CONCLUSIONS: In GARFIELD-AF, previous acute coronary syndromes are associated
with worse 2-year outcomes and a greater likelihood of under-treatment with OAC,
while two-thirds of patients receive AP therapy. Major bleeding was more common
with previous acute coronary syndromes, even after adjusting for all risk
factors.

Copyright © 2019 Elsevier Inc. All rights reserved.

DOI: 10.1016/j.amjmed.2019.06.008
PMID: 31306621 [Indexed for MEDLINE]

Know more about