New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease The EXCEL Trial

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:71

Article

Kosmidou, Ioanna^1,2  Chen, Shmuel¹  Kappetein, A. Pieter³  Serruys, Patrick W.⁴  Gersh, Bernard J.⁵  Puskas, John D.⁶  Kandzari, David E.⁷  Taggart, David P.⁸  Morice, Marie-Claude⁹  Buszman, Pawel E.^10,11  Bochenek, Andrzej^10,11  Schampaert, Erick¹²  Page, Pierre¹²  Sabik, Joseph F., III¹³  McAndrew, Thomas¹  Redfors, Bjorn¹  Ben-Yehuda, Ori^1,14  Stone, Gregg W.^1,14 

[1] Cardiovasc Res Fdn, Clin Trials Ctr, New York, NY USA

[2] St Francis Hosp, Arrhythmia Ctr, Dept Cardiol, Roslyn, NY USA

[3] Erasmus MC, Thoraxctr, Rotterdam, Netherlands

[4] Imperial Coll Sci Technol & Med, London, England

[5] Mayo Clin, Coll Med, Dept Cardiovasc Med, Rochester, MN USA

[6] Icahn Sch Med Mt Sinai, New York, NY 10029 USA

[7] Piedmont Heart Inst, Atlanta, GA USA

[8] John Radcliffe Hosp, Dept Cardiac Surg, Oxford, England

[9] Inst Cardiovasc Paris Sud, Ramsay Gen Sante, Paris, France

[10] Med Univ Silesia, Katowice, Poland

[11] Amer Heart Poland, Ustron, Poland

[12] Hop Sacre Coeur Montreal, Montreal, PQ, Canada

[13] UH Cleveland Med Ctr, Dept Surg, Cleveland, OH USA

[14] Columbia Univ, Med Ctr, NewYork Presbyterian Hosp, New York, NY 10019 USA

关键词: atrial fibrillation;    coronary artery bypass grafting;    left main disease;    mortality;    percutaneous coronary intervention;    prognosis;    stroke;   

DOI  :  10.1016/j.jacc.2017.12.012

来源: Elsevier

【 摘 要 】

BACKGROUND 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). OBJECTIVES This study sought to determine the incidence of NOAF following PCI and CABG for LMCAD and its effect on 3-year cardiovascular outcomes. METHODS 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. RESULTS 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). CONCLUSIONS 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]; (c) 2018 by the American College of Cardiology Foundation.

【 授权许可】

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