Prognostic significance of atrial fibrillation/flutter following acute myocardial infarction in patients with

diabetes mellitus

M.Gashi,E.Pllana,D.Kocinaj,S.Rexhepi

University Clinical Center of Kosovo, Prishtine

Introduction_______________________________________

• Any type of infarct can lead to an abnormal conduction interface which may lead to re-entry rhythm mechanism,

and • any infarct can lead to impaired LV filling, leading to

acute atrial enlargement causing atrial arrhythmias including AF.

__________________________________________ Sakata K,Kurihara H,Iwamori K et al. Clinical and prognostic significance of atrial fibrillation in acute myocardial

infarction Am.J Cardiol. 1997; 80: 1522-1527.

Pizzeti F, Turrazza FM, Franzosi MG et al. on behalf of the GISSI-3 investigators.Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction:the GISSI-3 data Heart 2001; 86:527-532.

Introduction_______________________________________

• AF is observed in up to 20% of AMI patients complicating AMI.

• AF seen during AMI is reported to be associated with longer hospitalization, higher in-hospital and long term mortality, and

• An increased incidence of stroke compared with the patient without AF

________________________________________ Rather Soberer AK,Weinfurt KP et al.Acute myocardial Infarction complicated by atrial fibrillation

in the elderly.Prevalence and outcames.Circulation 2000;101: 969-974

Introduction_______________________________________

• Despite its frequent occurrence the prognostic significance of AF complicating AMI remains controversial.

• Although some studies have identified increased in-hospital and long term mortality associated with AF,

• Others have found no independent effect.

______________________________ Sakata K,Kurihara H,Iwamori K et al. Clinical and prognostic significance of atrial

fibrillation in acute myocardial infarction Am.J Cardiol. 1997; 80: 1522-1527.

Materials and Methods_______________________________________

• We evaluated 2667 pts treated for acute myocardial infarction from 2003-2008 in our CCU

• We limited our analysis to patients presenting with the confirmed AMI (2 of the following 3 criteria):

- chest pain during the prior 48 hours - two fold elevation in CK (elevation CK-MB level

> 6% - diagnostic ECG changes

Study end points_______________________________________

• The aims of our study were to assess the occurrence of AF/F in a population of patients during AMI with diabetes mellitus during hospitalization, and

• To determine the prognostic impact of AF on in hospital mortality compared to the patients with sinus rhythm.

Materials and Methods_______________________________________

• The diagnosis of onset AF was based on a patient's follow-up ECG at the time of hospitalization and last recording before the patient was discharged from the clinic or died.

• During the hospitalization all patients were examined by cardiologist.

Materials and Methods_______________________________________

The following information was recorded: - medical history - physical examination - Killip classification - ECG - echocardiography - resting blood pressure - heart rate and - blood samples Since this was part of routine clinical practice in the

CCU, patients were not asked to provide written consent for collecting off clinical data

Results_______________________________________

• During the inclusion period a total of 2667 pts with AMI were analyzed.

• Of these, 386 pts (14.5%) suffered from AF/F.

• From 386 pts with AF/F 117 pts (31.5%) were with diabetes mellitus.

Results_______________________________________

2667 pts with AMI

2281 pts (85.5%)with SR

386 pts (14.5%)

suffered from AF/F.

117 pts (31.5%)

with DM

Table 1. Baseline characteristics of the 2667 patients with AMI_______________________________________________________________ SR group AF/F group p< 2281 (85.5%) 386 (14.5%) value

Age (years) 61.2 ± 15.2 67.9 ± 16.7 <0.001

Gender (% male) 50.4 49.3 ns

LVEF(%) 45.4 ± 6.2 37.2 ± 5.5 < 0.001

Heart rate (bpm) 72.3 ± 11.6 82.6 ± 12.2 ns

Systolic BP (mmHg) 137.5 ± 15.7 128.3 ± 11.9 ns

Diastolic BP (mmHg) 77.5 ± 9.6 73.4 ± 9.2 ns

History of stroke (%) 1.2 1.8 ns

History of hypertension (%) 26.4 32.5 0.07

Diabetes mellitus (%) 19.7 31.5 <0.001

History of MI (%) 34.3 53.8 <0.001

Results

____________________________

• In patients with diabetes mellitus and low LVEF presence of AF/F was associated with significant increase in hospital mortality ( HR 1.45; CI 1.05-2.06; p=0.02) compared to the patients with SR.

• Sustained AF during hospitalization was associated with the risk of dying, relative risk=1.6 (95% CI 1.4-1.9).

Discussion_______________________________

• The main result of this study is that the occurrence of AF during AMI in patients with diabetes mellitus is associated with increased mortality.

• The increased mortality appeared to be higher in patients with severe LV systolic dysfunction.

Discussion_______________________________

The limitations of this study are:

• All the AF patients were pooled together as a single category without classification and pooling AF and atrial flutter together.

• There are no data of AF suppressed with ACE, and with class III anti-arrhythmic drugs in post AMI during hospitalization

Conclusion_______________________________

• AF and atrial flutter often occurs during AMI in patients with diabetes mellitus, and

• Our analyses demonstrated that AF and atrial flutter were an independent predictor of an increased in hospital mortality.

Thank you