Abstract

BACKGROUND: Many patients with atrial fibrillation have concomitant coronary artery disease with or without acute coronary syndromes and are in the 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 Mar-2010 and Sep-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, OAC (oral anticoagulation)±AP (antiplatelet therapy) and usual care. RESULTS: 10.5% of 39,679 patients had a history of acute coronary syndromes. At 2-year follow-up, patients with prior acute coronary syndromes had a higher adjusted risks of stroke/systemic embolism (hazard ratio: 1.39, 95% confidence interval: 1.08-1.78), major bleeding (1.30, 0.95-1.79), all-cause mortality (1.34, 1.21-1.49), cardiovascular mortality (1.85, 1.51-2.26) and new acute coronary syndromes (3.42, 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, 22.2% in the acute coronary syndromes group received dual AP therapy with (7.5%) or without OAC (14.7%). Among patients with moderate/high risk for stroke/systemic embolism, fewer in the acute coronary syndromes group received OAC with or without AP therapy (CHA2DS2-VASc 2: 52.1% vs 64.7%; CHA2DS2-VASc ≥3: 62.0% vs 70.8%) and the majority with a HAS-BLED score≥3 were on AP therapy (83.8% vs 65.6%). 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.