TY - JOUR
T1 - New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease
T2 - The EXCEL Trial
AU - Kosmidou, Ioanna
AU - Chen, Shmuel
AU - Kappetein, A. Pieter
AU - Serruys, Patrick W.
AU - Gersh, Bernard J.
AU - Puskas, John D.
AU - Kandzari, David E.
AU - Taggart, David P.
AU - Morice, Marie Claude
AU - Buszman, Paweł E.
AU - Bochenek, Andrzej
AU - Schampaert, Erick
AU - Pagé, Pierre
AU - Sabik, Joseph F.
AU - McAndrew, Thomas
AU - Redfors, Björn
AU - Ben-Yehuda, Ori
AU - Stone, Gregg W.
N1 - Funding Information:
The EXCEL trial was funded by Abbott Vascular. Dr. Kappetein is an employee of Medtronic. Dr. Serruys is a consultant for Abbott Laboratories, AstraZeneca Pharmaceuticals, Biotronik, Cardialysis B.V., GLG Research, Medtronic, Sino Medical Sciences Technology, Inc., Société Europa Digital & Publishing, Svelte Medical Systems, Inc., Volcano Europe B.V.B.A., and Q3Medical Devices, Ltd. Dr. Gersh is a consultant for Boston Scientific and Medtronic. Dr. Kandzari has received grant support from Abbott Vascular, Boston Scientific, Medtronic, Biotronik, and Medinol; and is a consultant for Boston Scientific, Medtronic, Micell Technologies, and Biotronik. Dr. Schampaert is a consultant for Abbott Vascular, Boston Scientific, Medtronic, and Philips Medical. Dr. Sabik III is a consultant for Medtronic, Edwards Lifesciences, and Sorin. Dr. Stone’s employer, Columbia University, receives royalties from Abbott Vascular for sale of the MitraClip. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Publisher Copyright:
© 2018 American College of Cardiology Foundation
PY - 2018/2/20
Y1 - 2018/2/20
N2 - 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.
AB - 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.
KW - atrial fibrillation
KW - coronary artery bypass grafting
KW - left main disease
KW - mortality
KW - percutaneous coronary intervention
KW - prognosis
KW - stroke
UR - http://www.scopus.com/inward/record.url?scp=85044865020&partnerID=8YFLogxK
U2 - 10.1016/j.jacc.2017.12.012
DO - 10.1016/j.jacc.2017.12.012
M3 - Article
C2 - 29447735
AN - SCOPUS:85044865020
VL - 71
SP - 739
EP - 748
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
SN - 0735-1097
IS - 7
ER -