Atrial fibrillation acute myocardial infarction
| Conduction | ||
Sinus rhythm  |
Atrial fibrillation  | |
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| ICD-10 | I48 |
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| ICD-9 | 427.31 |
| DiseasesDB | 1065 |
| MedlinePlus | 000184 |
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Atrial Fibrillation Microchapters | |
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Special Groups | |
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Diagnosis | |
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Treatment | |
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Cardioversion | |
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Anticoagulation | |
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Surgery | |
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Case Studies | |
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Atrial fibrillation acute myocardial infarction On the Web | |
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Directions to Hospitals Treating Atrial fibrillation acute myocardial infarction | |
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Risk calculators and risk factors for Atrial fibrillation acute myocardial infarction | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Acute MI patients with the AF have been shown to have an increased incidence of in-hospital mortality and worst prognosis.[1] The incidence of stroke is also higher in patients with MI and AF than those without AF.[2]
Epidemiology & Demographics
- There are varied estimates about incidence and prevalence of atrial fibrillation (AF, Afib) in patients with coronary artery disease(CAD).
- Coronary Artery Surgery Study (CASS) reported that AF was found to be present in 0.6% patients with CAD[3].
- A community-wide study[4] reported an overall incidence of Afib complicating myocardial infarction (MI) to be 16%.
- Majority of atrial arrhythmias in the setting of MI usually occurs within first 72hrs[5].
Pathophysiology
Atrial fibrillation in the setting of acute myocardial infarction is due to:
- Atrial dysfunction secondary to atrial ischemia/infarction as a consequence of
- Proximal left circumflex artery occlusion prior to atrial branch[6].
- Poor blood flow down the atrioventricular branch of the right coronary artery which affect the functioning of AV and SA node.
- Increased left atrial pressure as a consequence of left ventricular dysfunction.
- Sympathetic stimulation.
- Iatrogenic factors.
Clinical trial data
- Coronary Artery Surgery Study (CASS) involving 18,343 patients with CAD reported that AF was found to be present in 116 (0.6%) patients[3].
- GUSTO-I trial[2] involving 40,891 patients reported 2.5% patients had Afib at the time of admission and 7.9% patients had Afib at the time of randomization who frequently had triple vessel disease. The study concluded atrial fibrillation to be an independent predictor of stroke and 30-day mortality in the setting of acute MI.
- GUSTO-III trial[7] involving 13,858 patients reported patients with AF had a greater 30-day and 1-year mortality.
- GISSI-3 trial[8] and the TRACE trial[9] concluded AF after MI was a independent worst prognostic indicator for both short-term and long-term mortality.
- PURSUIT trail[10] demonstrated increased 30-day and 6-month mortality in patients who developed AF in the setting of Unstable angina/NSTEMI.
- Meta-Analysis[11] involving 278 854 patients from 1970 – 2010 reported that the presence of a new onset AF after MI was associated with increased mortality even after adjusting several important risk factors for AF. Mortality odds ratio associated with AF was 1.46 while that of new onset AF was 1.37 and prior AF was 1.28 suggesting that AF is no longer a nonsevere event during MI.
Treatment
The management of new onset AF after MI is important, because majority of the patients with hemodynamic compromise during Afib is a result of rapid ventricular rate which increases myocardial oxygen demand, thereby exacerbating ongoing ischemia and possibly decreasing cardiac output.
If hemodynamically unstable:
- Direct-current cardioversion (biphasic shock of 100 J or monophasic shock of 200 J)
- If non-responsive to cardioversion or Afib recurs, IV-amiodarone is indicated to control rate and maintain sinus rhythm. Dofetilide is also another effective drug to maintain sinus rhythm in patients with new onset AF after MI[12].
- Hemodynamic compromise in AF is mostly due to rapid ventricular rate, for which IV-beta blocker or IV-verapamil is recommended as amiodarone and digoxin only gradually slow the atrioventricular conduction.
If hemodynamically stable:
- Rate control with IV-beta blocker (unless contra-indicated) and anticoagulation is indicated.
- Cardioversion is indicated in patients without a history of AF prior to MI.
- Long-term antiarrhythmic therapy is indicated only in cases of recurrent AF associated with heart failure or severe left ventricular systolic dysfunction[13].
Anticoagulation for new onset sustained Afib after MI
- If the new onset AF is of known duration, AF can be cardioverted within 24hours without the need for anticoagulation after cardioversion.
- If the AF is of unknown duration, Transesophageal echocardiography (TEE) is recommended before cardioversion (depending on the patients hemodynamic status) and anticoagulation with heparin followed by warfarin or dabigatran after cardioversion.
- Anticoagulation is usually not recommended for patients with a single episode of AF after MI, however patients with recurrent or chronic AF should receive oral anticoagulation based on the CHADS2 Score assessment.
Prevention
Early statin therapy[14] is indicated in ischemic heart disease, after cardiac bypass surgery, and to reduce AF recurrences. However it is not recommended to prevent AF in patients with MI.
ACCF/AHA/HRS 2011 Guidelines for Management of Patients With Atrial Fibrillation- Acute Myocardial Infarction (DO NOT EDIT) [15]
| Class I |
| "1. Direct-current cardioversion is recommended for patients with severe hemodynamic compromise or intractable ischemia, or when adequate rate control cannot be achieved with pharmacological agents in patients with acute MI and AF (Level of Evidence: C) " |
| "2. Intravenous amiodarone is recommended to slow a rapid ventricular response to AF and improve LV function in patients with acute MI. (Level of Evidence: C) " |
| "3. Intravenous beta blockers and nondihydropyridine calcium antagonists are recommended to slow a rapid ventricular response to AF in patients with acute MI who do not have LV dysfunction, bronchospasm, or AV block. (Level of Evidence: C) " |
| "4. For patients with AF and acute MI, unfractionated heparin is recommended (aPTT 1.5 to 2.0 times control), unless contraindicated. (Level of Evidence: C) " |
| Class III (Harm) |
| "1. Class IC antiarrhythmic drugs are not recommended in patients with AF and acute MI.(Level of Evidence: C) " |
| Class IIa |
| "1. Intravenous digitalis is reasonable to slow a rapid ventricular response and improve LV function in patients with acute MI and AF associated with severe LV dysfunction and HF (Level of Evidence: C) " |
Vote on and Suggest Revisions to the Current Guidelines
Guideline Resources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [17]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [18]
References
- ↑ Rathore SS, Berger AK, Weinfurt KP, Schulman KA, Oetgen WJ, Gersh BJ et al. (2000) Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes. Circulation 101 (9):969-74. PMID: 10704162
- ↑ 2.0 2.1 Crenshaw BS, Ward SR, Granger CB, Stebbins AL, Topol EJ, Califf RM (1997) Atrial fibrillation in the setting of acute myocardial infarction: the GUSTO-I experience. Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries. J Am Coll Cardiol 30 (2):406-13. PMID: 9247512
- ↑ 3.0 3.1 Cameron A, Schwartz MJ, Kronmal RA, Kosinski AS (1988). "Prevalence and significance of atrial fibrillation in coronary artery disease (CASS Registry)". The American Journal of Cardiology. 61 (10): 714–7. PMID 3258467. Retrieved 2011-04-19. Unknown parameter
|month=ignored (help) - ↑ Goldberg RJ, Seeley D, Becker RC, Brady P, Chen ZY, Osganian V, Gore JM, Alpert JS, Dalen JE (1990). "Impact of atrial fibrillation on the in-hospital and long-term survival of patients with acute myocardial infarction: a community-wide perspective". American Heart Journal. 119 (5): 996–1001. PMID 2330889. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ JAMES TN (1961). "Myocardial infarction and atrial arrhythmias". Circulation. 24: 761–76. PMID 14451030. Retrieved 2011-04-18. Unknown parameter
|month=ignored (help) - ↑ Hod H, Lew AS, Keltai M, Cercek B, Geft IL, Shah PK, Ganz W (1987). "Early atrial fibrillation during evolving myocardial infarction: a consequence of impaired left atrial perfusion". Circulation. 75 (1): 146–50. PMID 3791600. Retrieved 2011-04-19. Unknown parameter
|month=ignored (help) - ↑ Wong CK, White HD, Wilcox RG, Criger DA, Califf RM, Topol EJ, Ohman EM (2000). "New atrial fibrillation after acute myocardial infarction independently predicts death: the GUSTO-III experience". American Heart Journal. 140 (6): 878–85. PMID 11099991. Retrieved 2011-04-18. Unknown parameter
|month=ignored (help) - ↑ Pizzetti F, Turazza FM, Franzosi MG, Barlera S, Ledda A, Maggioni AP, Santoro L, Tognoni G (2001). "Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction: the GISSI-3 data". Heart (British Cardiac Society). 86 (5): 527–32. PMC 1729969. PMID 11602545. Retrieved 2011-04-18. Unknown parameter
|month=ignored (help) - ↑ Pedersen OD, Bagger H, Køber L, Torp-Pedersen C (1999). "The occurrence and prognostic significance of atrial fibrillation/-flutter following acute myocardial infarction. TRACE Study group. TRAndolapril Cardiac Evalution". European Heart Journal. 20 (10): 748–54. PMID 10329066. Retrieved 2011-04-18. Unknown parameter
|month=ignored (help) - ↑ Al-Khatib SM, Pieper KS, Lee KL, Mahaffey KW, Hochman JS, Pepine CJ, Kopecky SL, Akkerhuis M, Stepinska J, Simoons ML, Topol EJ, Califf RM, Harrington RA (2001). "Atrial fibrillation and mortality among patients with acute coronary syndromes without ST-segment elevation: results from the PURSUIT trial". The American Journal of Cardiology. 88 (1): A7, 76–9. PMID 11423065. Retrieved 2011-04-18. Unknown parameter
|month=ignored (help) - ↑ Jabre P, Roger VL, Murad MH, Chamberlain AM, Prokop L, Adnet F, Jouven X (2011). "Mortality Associated With Atrial Fibrillation in Patients With Myocardial Infarction: A Systematic Review and Meta-Analysis". Circulation. doi:10.1161/CIRCULATIONAHA.110.986661. PMID 21464054. Retrieved 2011-04-18. Unknown parameter
|month=ignored (help) - ↑ Køber L, Bloch Thomsen PE, Møller M, Torp-Pedersen C, Carlsen J, Sandøe E, Egstrup K, Agner E, Videbaek J, Marchant B, Camm AJ (2000). "Effect of dofetilide in patients with recent myocardial infarction and left-ventricular dysfunction: a randomised trial". Lancet. 356 (9247): 2052–8. PMID 11145491. Retrieved 2011-04-19. Unknown parameter
|month=ignored (help) - ↑ Eldar M, Canetti M, Rotstein Z, Boyko V, Gottlieb S, Kaplinsky E, Behar S (1998). "Significance of paroxysmal atrial fibrillation complicating acute myocardial infarction in the thrombolytic era. SPRINT and Thrombolytic Survey Groups". Circulation. 97 (10): 965–70. PMID 9529264. Retrieved 2011-04-19. Unknown parameter
|month=ignored (help) - ↑ Danchin N, Fauchier L, Marijon E, Barnay C, Furber A, Mabo P, Bernard P, Blanc JJ, Jouven X, Le Heuzey JY, Charbonnier B, Ferrières J, Simon T (2010). "Impact of early statin therapy on development of atrial fibrillation at the acute stage of myocardial infarction: data from the FAST-MI register". Heart (British Cardiac Society). 96 (22): 1809–14. doi:10.1136/hrt.2010.201574. PMID 20965993. Retrieved 2011-04-18. Unknown parameter
|month=ignored (help) - ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA; et al. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". J Am Coll Cardiol. 57 (11): e101–98. doi:10.1016/j.jacc.2010.09.013. PMID 21392637.
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2006) ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114 (7):e257-354. DOI:10.1161/CIRCULATIONAHA.106.177292 PMID: 16908781
- ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199
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