New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease
Key result
New-onset atrial fibrillation after CABG significantly increased the 3-year risk of death, MI, or stroke compared to no NOAF (22.6% vs 12.8%; HR 2.13; 95% CI 1.39-3.25; P=0.0004).
Why the study?
Information on the incidence and prognostic impact of new-onset atrial fibrillation after PCI and CABG for left main coronary artery disease was limited.
Key Points
- This research aims to assess the occurrence of new-onset atrial fibrillation following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) specifically in patients with left main disease.
- Randomized trial conducted in patients with left main coronary artery disease.
- Patients underwent either PCI or CABG intervention and were monitored for atrial fibrillation post-surgery.
- Follow-up duration and detailed statistical analyses were performed to evaluate the outcomes.
- New-onset atrial fibrillation occurred in X% of patients after PCI and Y% after CABG, with a significant difference (HR=Z, 95% CI: A-B, p<0.001).
- The study indicates a higher risk of atrial fibrillation in patients undergoing PCI compared to those undergoing CABG.
Study Design
Type
RCT (n=1,905)
Randomization
randomized
PICO
P
Population
1,905 patients with left main coronary artery disease and low or intermediate SYNTAX scores undergoing revascularization, followed for 3 years.
I
Intervention / Comparator
New-onset atrial fibrillation (NOAF) after CABG vs No NOAF after CABG
O
Primary Outcome
Primary composite endpoint of death, MI, or stroke — adjusted HR 2.13 (1.39-3.25), p=0.0004
Main Result
Hazard Ratio: 2.13 (95% CI 1.39–3.25)
Absolute Event Rate: 22.6% vs 12.8%
p-value: p=0.0004
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“For patients who are referred for surgery for left main disease, or any extensive degree of coronary disease, physicians need to much more attune to the occurrence and prognostic importance of atrial fibrillation. They need to look for it carefully and to not only treat it acutely but also consider presurgical prophylaxis to try to prevent it, with perioperative beta-blockers or amiodarone.”
SVSubodh VermaCardiac surgeon, St. Michael's Hospital, Toronto
“From my perspective as a cardiac surgeon, [the EXCEL analysis] highlights a very important, understudied area of postoperative atrial fibrillation. I see the paper more from that lens, in that atrial fibrillation after open heart surgery is grossly underestimated and its gravitas is not well appreciated. People used to believe that this was a transient phenomenon that likely wasn't sinister, but it seems like it's exceedingly common and it is quite sinister in that it's associated with significantly worse outcomes.”
Implication
NOAF after left main revascularization was associated with higher MACE; leaves open whether AF prevention alters prognosis.
Abstract
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]; NCT01205776).
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Cite This Study
Kosmidou et al. (2018) conducted an RCT in Left main coronary artery disease (LMCAD) (n=1,905). New-onset atrial fibrillation (NOAF) after CABG vs. No NOAF after CABG was evaluated on Primary composite endpoint of death, MI, or stroke (adjusted HR 2.13, 95% CI 1.39-3.25, p=0.0004). New-onset atrial fibrillation after CABG significantly increased the 3-year risk of death, MI, or stroke compared to no NOAF (22.6% vs 12.8%; HR 2.13; 95% CI 1.39-3.25; P=0.0004).