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Funding Acknowledgements Type of funding sources: None. INTRODUCTION Atrial fibrillation (AF) is an adverse prognostic factor during acute coronary syndrome (ACS). Current evidence recommends dual antithrombotic therapy (DAT), 1 antiplatelet drug and 1 anticoagulant drug, as the default strategy after nonST elevation ACS. AIM To identify the clinical differences and prognosis of AF type-new onset (nAF) or pre-existing (pFA)- during ACS, to evaluate antithrombotic strategy at hospital discharge (HD) and its impact on haemorrhagic and ischemic events. METHODS We performed a retrospective observational cohort study including 3241 patients (pts) with ACS (mean age 64 years, 77.5% male) admitted to a single center over a 6-year period, with 12-months follow-up. RESULTS AF rhythm was identified in 11.2% pts, of whom 63.2% presented nAF and 36.8% pAF. When AF types where compared, pts with pAF had a higher prevalence of cardiovascular (Cv) comorbidities, including hypertension (p < 0.001), previous ACS (p = 0.03), valvular disease (p = 0.01) or stroke (p = 0.05), had greater left atrial diameter (p < 0.001) and were less likely to have significant coronary lesions (p = 0.05). Pts with nAF more frequently presented with STelevation ACS (p < 0.001) and had a lower Hemoglobin nadir (p < 0.001). The independent predictors of nAF in ACS were age (OR 1.1, p< =0.001), LVEF ≤ 40% (OR 2.2, p = 0.001), STelevation ACS (OR 2.6, p< =0.001) and previous valvular disease (OR 3.5, p< =0.01). Compared with the population without AF, nAF was a predictor of in-hospital death (OR 2.9, p = 0.027) and in-hospital composite endpoint (death, stroke, reinfarction and cardiogenic shock) (OR 2.5, p = 0.001) in multivariate analysis, but pAF wasn’t. During 12-months follow-up of pts with ACS and AF, there was no difference regarding death or follow-up composite endpoint (death, stroke and ACS) between the AF types.Regarding antithrombotic therapy, nAF pts were less often anticoagulated (p < 0.001) and pAF pts where more often treated with triple antithrombotic therapy (TAT) at HD (<0.001). Most of the pts with TAT stopped the second antiplatelet at agent 6-months (43.8%) or 12 months (25.5%) after HD. During 12-months follow-up, pts discharged with TAT had trend towards more haemorrhagic events (TAT 6.2% vs DAT2.7%,p = 0.69) and both groups had similar ischaemic events (death, ACS, stroke) (TAT 20.9% vs DAT23.7%,p = 0.714). In multivariate analysis the choice of TAT or DAT wasn’t a predictor of ischaemic events. CONCLUSIONS In ACS, pts with nAF had worst in-hospital outcomes than pts with pAF. Regarding antithrombotic strategy at HD pts with nFA were less often anticoagulated and less often treated with TAT. In our study the choice between DAT or TAT had no statistical impact on follow-up outcomes.

Atrial fibrillation (AF) is a common complication in acute coronary syndrome (ACS). However, treating patients (pts) with new-onset AF (NOAF) after an ACS remains a challenge. Although it seems intuitive that pts who develop AF within the first 48h have increased morbidity and mortality, your prognosis is unclear because there are no robust studies in the literature to confirm this association. Aim To characterize the population of pts who developed NOAF in the first 48 hours after an ACS and to compare the prognosis between these pts and pts who didn't develop AF. Methods 2916 ACS pts admitted consecutively in our coronary care unit during 6 years were analyzed retrospectively. Of these pts, 343 (11.7%) had AF within the first 48h, of which 99 (3.4%) had pre-existing AF and 243 (8.3%) presented NOAF. Pts were divided into two groups: group 1 -ACS pts who developed NOAF in the first 48h (n=243; 8.8%); group 2 – ACS pts who did not develop AF (n=2517; 91.2%). Pts with pre-existing AF were excluded (n=156; 5.4%). Primary endpoint were the occurrence of death at 6 months; follow-up was completed in 95.8% of pts. Results Group 1 pts were older (72±12 vs 62±13, p<0.001), with higher proportion of women (30,9% vs 20,9%, p<0.001), hypertensive (78,5% vs 60,7%, p<0.001), smokers (17,4% vs 32,6%, p<0.001), previous CABG (7,9% vs 3,8%, p=0.06) and stroke (10,7% vs 6,8%, p=0.035). Group 1 had a higher proportion of STEMI pts (58,5% vs 46,5%, p<0.001) and, during hospitalization, had more often respiratory infection (p<0.001), malignant arrhythmias (p<0.001), heart failure (p<0.001), stroke (p=0.001), higher values of NT-proBNP (p<0.001) increased C-reactive protein levels (p<0.001), leukocytes (p=0.020), peak of TropI (p=0.029) and creatinine (p<0.001). On echocardiography, group1 had greater LA diameter (45±6 VS 41±5mm, p<0.001), more frequent significant mitral regurgitation (13,9% vs 2,9%, p<0.001), worst LVEF (41±10% vs 46±10%, p<0.001) and a higher value of pulmonary artery pressure (39±12 vs 24±10, p<0.001). Group 1 were less likely to have undergone coronary revascularization (84% vs 74%, p=0.005). In multivariate analysis, age ≥75 (OR 1.05, p<0.001), LVEF ≤40% (OR 2.50, p<0.001), LA diameter (OR 1.59, p=0.027), more significant mitral regurgitation (OR 2.49, p=0.001) and Killip class >1 (OR 1.51, p=0.015) remained independent predictors of NOAF. In multivariate analysis and after adjusting for different baseline characteristics, pts with NOAF have the same risk of 6-months mortality compared to those who didn't develop AF [OR 1.03, p=0.91]. Conclusion The incidence of NOAF was 8.8% in our population, which is similar to the literature. Age, LVEF, LA diameter, a significant mitral regurgitation and Killip class >1 were independent predictors of NOAF after ACS. Pts with NOAF in the first 48h after an ACS had worse clinical manifestations during hospitalization but no higher 6-months mortality risk. Funding Acknowledgement Type of funding source: None

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