New-onset atrial fibrillation after PCI or CABG for left main disease : The EXCEL Trial

Selected in the Journal of the American College of Cardiology by S. Brugaletta



Ioanna Kosmidou, Shmuel Chen, A. Pieter Kappetein, Patrick W. Serruys, Bernard J. Gersh, John D. Puskas, David E. Kandzari, David P. Taggart, Marie-Claude Morice, Paweł E. Buszman, Andrzej Bochenek, Erick Schampaert, Pierre Pagé, Joseph F. Sabik III, Thomas McAndrew, Björn Redfors, Ori Ben-Yehuda and Gregg W. Stone




February 2018


Read the abstract

My Comment

Why this study – the rationale/objective?

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). This study sought to determine the incidence of NOAF following PCI and CABG for LMCAD and its effect on 3-year cardiovascular outcomes.

How was it executed – the methodology?

This is a sub-analysis of the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, which randomized 1,905 patients with LMCAD and low or intermediate SYNTAX scores to PCI with everolimus-eluting stents versus CABG.

Outcomes were analyzed according to the development of NOAF
 during the initial hospitalization following revascularization.

What is the main result?

  • 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).

Critical reading and the relevance for clinical practice

All trials so far comparing PCI vs. CABG have failed to demonstrate a clear superiority of PCI over CABG. The EXCEL trial, focusing on patients with left main disease and a Syntax score 32, was the first to show at least no inferiority of PCI vs. CABG at 3-year follow-up. It is well known that incidence of stroke is higher in CABG than in PCI patients. The present subanalysis, analyzing the incidence of NOAF and its effect on cardiovascular events, came to the conclusion that patients who developed NOAF had a worse prognosis than those who did not. Despite study limitations, this is an interesting finding if we think about relationship between NOAF and CABG and with subsequent stroke, and it may offer new arguments in favor of PCI over CABG in selected patients. Moreover, a further research is needed on how to prevent NOAF after CABG and how to reduce its detrimental role in determining subsequent cardiovascular events.

In particular could the use of new oral anticoagulant therapy instead of anti-vitamin K treatment be useful? An answer is needed not only from interventional cardiologists but also from cardiac surgeons.

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