Abstract
Background: Atrial fibrillation (AF) has been identified as a major risk factor for mortality after acute coronary syndrome (ACS). However, the long-term risk of ischemic stroke associated with new-onset atrial fibrillation (NOAF) in ACS remains controversial, and its gender-specific association is unknown. Methods: We analyzed the data of 10,137 ACS survivors included in a multicenter, prospective registry for Korean patients with acute myocardial infarction (AMI) between January 2004 and August 2014. Subjects were categorized into three groups (non-AF vs. NOAF vs. previous AF) based on medical history and electrocardiographic evidence of AF, either at admission or during hospitalization. Results: Among the total study population (72.3% men), 370 patients (3.6%) had NOAF and 130 (1.3%) had previous AF. During a median follow-up of 61 months (interquartile range, 38.8 to 89.3 months), 245 (2.4%) patients (218 (2.3%) non-AF vs. 15 (4.1%) NOAF vs. 12 (9.2%) previous AF, p < 0.001) experienced ischemic stroke. After adjustment for confounding variables, both NOAF (adjusted hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.09–3.24, p = 0.024) and previous AF (adjusted HR 4.00, 95% CI 2.03–7.87, p < 0.001), along with older age, diabetes, current smoker, and previous stroke were independent risk factors of ischemic stroke. In the gender-stratified analysis, men with previous AF but not NOAF had a significantly higher risk of ischemic stroke (adjusted HR 4.14, 95% CI 1.79–9.55, p = 0.001) than those without AF. In women, NOAF (adjusted HR 2.54, 95% CI 1.21–5.35, p = 0.014) as well as previous AF (adjusted HR 3.72, 95% CI 1.16–11.96, p = 0.028) was a strong predictor of ischemic stroke, and the predictive value was comparable to that of previous AF among patients with a CHA2DS2-VASc score ≥ 2. Conclusions: Both NOAF and previous AF were associated with ischemic stroke after AMI, but the impact of NOAF as a risk factor of ischemic stroke was significant only in women.
Highlights
Atrial fibrillation (AF) is a common pre-existing comorbidity in patients with acute coronary syndrome (ACS) and is a frequent complication of ACS, with an incidence ranging from 6% to 21% [1,2]
Women had a lower diastolic blood pressure (BP) level, higher heart rate, lower left ventricular ejection fraction (LVEF), and higher levels of HbA1c and low-density lipoprotein (LDL) cholesterol at admission than men and were more likely to present with a higher Killip class (≥2)
Our results suggest that women with post-MI new-onset atrial fibrillation (NOAF) should be managed more aggressively according to the guidelines, targeting effective anticoagulation, and control of modifiable risk factors for stroke following PCI for acute myocardial infarction (AMI)
Summary
Atrial fibrillation (AF) is a common pre-existing comorbidity in patients with acute coronary syndrome (ACS) and is a frequent complication of ACS, with an incidence ranging from 6% to 21% [1,2]. Unlike the previous AF that has been relatively well-established as a risk factor for ischemic stroke [5], the association of NOAF complicating ACS with risk of ischemic stroke is controversial [6,7]. In a recently published meta-analysis, Luo J. et al identified a significantly higher risk of ischemic stroke after ACS in patients with NOAF compared with those in sinus rhythm, but their results were obtained mostly from observational studies that examined in-hospital or short-term outcomes with different definitions of NOAF [8]. Gender differences in in-hospital management and outcomes following ACS have been observed, with less invasive therapy and a higher inhospital mortality rate in women than in men [14,15]. The differential impact of NOAF after ACS on the risk of ischemic stroke in men and women has not been determined
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