The Effect of Atrial Fibrillation on the Long-Term Mortality of Patients with Acute Coronary Syndrome: The TACOS Study

Abstract

<b><i>Introduction:</i></b> Atrial fibrillation (AF) is a frequent finding in acute coronary syndrome (ACS), but there is conflicting scientific evidence regarding its long-term impact on patient outcome. The aim of this study was to survey and compare the ≥10-year mortality of ACS patients with sinus rhythm (SR) and AF. <b><i>Methods:</i></b> Patients were divided into 2 groups based on rhythm in their 12-lead ECGs: (1) SR (<i>n</i> = 788) at hospital admission and discharge (including sinus bradycardia, physiological sinus arrhythmia, and sinus tachycardia) and (2) AF/atrial flutter (<i>n</i> = 245) at both hospital admission and discharge, or SR and AF combination. Patients who failed to match the inclusion criteria were excluded from the final analysis. The main outcome surveyed was long-term all-cause mortality between AF and SR groups during the whole follow-up time. <b><i>Results:</i></b> Consecutive ACS patients (<i>n</i> = 1,188, median age 73 years, male/female 58/42%) were included and followed up for ≥10 years. AF patients were older (median age 77 vs. 71 years, <i>p</i> < 0.001) and more often female than SR patients. AF patients more often presented with non-ST-elevation myocardial infarction (69.8 vs. 50.4%, <i>p</i> < 0.001), had a higher rate of diabetes (31.0 vs. 22.8%, <i>p</i> = 0.009), and were more often using warfarin (32.2 vs. 5.1%, <i>p</i> < 0.001) or diuretic medication (55.1 vs. 25.8%, <i>p</i> < 0.001) on admission than patients with SR. The use of warfarin at discharge was also more frequent in the AF group (55.5 vs. 14.8%, <i>p</i> < 0.001). The rates of all-cause and cardiovascular mortality were higher in the AF group (80.9 vs. 50.3%, <i>p</i> < 0.001, and 73.8 vs. 69.6%, <i>p</i> = 0.285, respectively). In multivariable analysis, AF was independently associated with higher mortality when compared to SR (adjusted HR 1.662; 95% CI: 1.387–1.992, <i>p</i> < 0.001). <b><i>Conclusion:</i></b> AF/atrial flutter at admission and/or discharge independently predicted poorer long-term outcome in ACS patients, with 66% higher mortality within the ≥10-year follow-up time when compared to patients with SR.

Prevalence and Impact of Concomitant Atrial Fibrillation in Patients Undergoing Percutaneous Coronary Intervention for Acute Myocardial Infarction

“…We found that AF is a surrogate marker of disease in patients with MI rather than an independent risk factor. This was in contrast to previous studies [11][12][13][14][15][16][17], and our study demonstrated this over a longer period…”

“…The reported prevalence of 2 of 13 concomitant AF in patients following acute MI varies widely, with reported rates ranging between 6 and 21% [7,8]. Previous studies have identified AF as an independent risk factor both for MI [7][8][9][10] and for mortality after MI [11][12][13][14][15][16][17]. However, it is unclear whether this is due to a causal effect of AF or whether the observed effect is a result of AF acting as a surrogate marker for other comorbidities that influence the outcome.…”

In-hospital mortality from acute coronary syndrome in Africa: a systematic review and meta-analysis

“…Therefore, there is a need for early identification of high-risk patients who would benefit from treatment with long-term mortality outcomes. 60,61 Our review found that acute stroke was among the most common nonfatal MACE in patients hospitalized with ACS. Although it was less common (3%) compared to other MACE found in this review, however, stroke could be associated with significant morbidity and mortality.…”

“…Therefore, there is a need for early identification of high-risk patients who would benefit from treatment with long-term mortality outcomes. 60 , 61 …”

Heterogeneity in the role of emergency physicians and treatment of acute atrial fibrillation in emergency departments—results of the International Atrial Fibrillation Background (AFiB) Study

“…However, some evidence suggests that rhythm control may be preferable for younger patients (under 70 years old), while rate control may be more suitable for older individuals with multiple comorbidities such as heart failure and hypertension [11]. Recent studies have reported benefits in achieving short-and long-term restoration of sinus rhythm [12,13]. For patients who remain symptomatic despite receiving adequate rate control therapy, cardioversion (CV) is the preferred approach [8,9].…”