A 72-year-old woman has undergone percutaneous coronary intervention with drug-eluting stent placement after presenting the previous day with an acute ST-elevation myocardial infarction. Her past medical history includes hypertension and hyperlipidemia, and her body mass index is 21 kg/m2. An echocardiogram obtained following her coronary intervention showed an ejection fraction of 35 percent. Overnight she developed atrial fibrillation with a rapid ventricular rate of 140 bpm accompanied by a precipitous drop in blood pressure with a systolic pressure of 70 mmHg as well as an increase in respiratory rate and new pulmonary congestion. As per recent STEMI guidelines, the patient was already taking metoprolol, lisinopril, clopidogrel and aspirin.
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Question 1 of 3
1. QuestionCategory: Case No. 4
The AHA/ACCF guidelines for the management of AF in patients with hemodynamic instability recommend:Correct
Various studies have estimated AF incidence among patients with STEMI ranging from 6 percent to 21 percent. [Schmitt 2009, p1038] The variation was largely dependent upon the study methodology, patient age and comorbidities, and treatment interventions (e.g. beta-blockers, ACE inhibitors, AT-II blockers, etc.).
Limited data are available to guide the management of patients with AF and STEMI, and recommendations are based on consensus. [Fuster 2011, p337] During the acute phase of AF, guidelines recommend direct-current cardioversion for patients with hemodynamic instability, intractable ischemia or when adequate rate control cannot be achieved with pharmacologic therapy. [Fuster 2011, p337] For hemodynamically stable patients with normal LV function, intravenous amiodarone, beta-blockers and nondihydropyridine calcium antagonists are recommended for slowing rapid ventricular responses to AF in patients with STEMI. [Fuster 2011, p337]Incorrect
Question 2 of 3
2. QuestionCategory: Case No. 4
As compared to patients with STEMI without AF, the prognosis of those with AF is associated with:Correct
Patients with STEMI and AF have an increased risk of in-hospital, 30-day and one-year mortality, as well as an increased risk of stroke. [Schmitt 2009, p1042; Fuster 2011, p337; Angeli 2012, p601; Podolecki 2012, p1689] The one-year mortality risk is particularly elevated among patients who develop AF after hospital admission. In one study of STEMI patients with AF, the odds ratio for one-year mortality was 1.16 (95 percent CI 1.11, p<0.05) among those who presented with AF compared to 1.51 (95 percent CI 1.44-1.58, p<0.05) among those who developed AF after hospital admission. [Rathore 2000, p969] This trend is unaffected by PCI. Another comparison found an odds ratio for one-year mortality of 3.04 (95 percent CI 1.4-7.48) among patients who developed AF after PCI, whereas AF on admission was not prognostically significant. [Kinjo 2003, p1150] Overall, patients with STEMI and AF have an increased risk of short- and long-term mortality independent of the type of reperfusion therapy employed. [Schmitt 2009, p1043]Incorrect
Question 3 of 3
3. QuestionCategory: Case No. 4
Which antithrombotic strategy is most appropriate for the patient in this case?Correct
Patients who undergo acute and elective PCI with stent implantation present a clinical challenge in terms of antithrombotic therapy. Both bare-metal stents and drug-eluting stents require dual antiplatelet therapy following implantation to prevent stent thrombosis. Patients with AF and a CHA2DS2-VASc ≥ 1 or 2 also require anticoagulation with warfarin or a novel anticoagulant to prevent stroke and thromboembolic events.
With CHA2DS2-VASc and HAS-BLED scores of 4 and 2, respectively, the patient in this case has a moderate-to-high risk of stroke and a relatively low risk of bleeding. Recent consensus recommendations from the European Society of Cardiology and U.S.-based authors recommend six months of triple therapy following stenting for patients with a low or intermediate bleeding risk. [Lip 2010, p1316; Faxon 2011, p580; Paikin 2010, p2069] Other recommendations are shown in Table 4.1.
Triple therapy is associated with higher rates of bleeding. [Ruiz-Nodar 2012, p459] However, a recent analysis of 590 consecutive patients with AF undergoing PCI with a CHA2DS2-VASc >1 suggests that the benefits outweigh the risks. [Ruiz-Nodar 2012, p459] The study compared outcomes among patients with low (HAS-BLED 0-2) and high (HAS-BLED ≥3) bleeding risks and among patients who received and did not receive antithrombotic therapy. Among patients with a high bleeding risk, 57.1 percent received triple therapy. As compared to patients who did not receive warfarin, those with warfarin had significantly lower one-year rates of mortality (9.3 percent versus 20.1 percent, p<0.01), major adverse cardiac events (13 percent versus 26.4 percent, p<0.01), but a higher rate of major bleeding (11.8 percent versus 4.0 percent, p=0.01). [Ruiz-Nodar 2012, p459]Incorrect