Introduction: Limited data are available regarding contemporary management of myocardial infarction (MI) in atrial fibrillation (AF) patients taking warfarin (WF) or direct oral anticoagulants (DOAC).
Methods: We analyzed patient characteristics, peri-infarct therapy, in-hospital bleeding and mortality stratified by home anticoagulation (AC): (1) no AC, (2) WF, (3) DOAC among STEMI and NSTEMI pts with AF treated at 761 US hospitals in the ACTION Registry-GWTG from 01/2015-12/2016. Multivariable logistic regression was used to examine the independent association between home AC and in-hospital outcomes.
Results: Percentages of 6,471 STEMI pts in each AC category were: no AC - 71.3%, WF - 15.7%, DOAC - 13.0%; and among 19,954 NSTEMI pts: no AC - 61.9%, WF - 22.8%, DOAC - 15.4%. STEMI pts on WF or DOAC were older, had more comorbidities, with higher CHA2DS2-VASc scores and were less likely to receive thrombolytics compared with no AC pts. Door-to-balloon times were slightly higher in those on WF, with similar rate of angiography within 24 hours and frequency of primary PCI in the 3 groups (Table). NSTEMI pts on no AC were more likely to undergo angiography or PCI within 24 hours compared with WF or DOAC pts. After multivariate adjustment, home WF or DOAC was not associated with increased in-hospital major bleeding compared with no AC. However, home WF (OR 0.78, 95%CI 0.61-1.00 in STEMI; OR 0.82, 95%CI 0.68-0.97 in NSTEMI) and, particularly, home DOAC (OR 0.61, 95%CI 0.46-0.81 in STEMI; OR 0.67, 95% CI 0.54-0.83 in NSTEMI) were associated with lower in-hospital mortality compared with no AC.
Conclusions: The majority of MI patients with prior AF (>60%) are not on oral AC. For MI patients with prior AF, home WF or DOAC therapy is not associated with an increased risk of in-hospital bleeding compared with no AC. These data suggest that in-hospital outcomes of acute MI patients with AF are not negatively affected by home DOAC therapy despite the perceived high bleeding risk.