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ASPECTS OF ANTITHROMBOTIC THERAPY IN PATIENTS WITH ATRIAL
FIBRILLATION AND CORONARY DISEASE (review)
Oktamova Rukhsora Otkirjonovna
Assistant, PhD student, Department of Internal Medicine in Family Medicine, Bukhara State
Medical Institute named after Abu Ali ibn Sino
https://orcid.org/0009-0001-7195-5125
Annotation:
Coronary artery disease (CAD) is the most common cardiovascular disease,
while atrial fibrillation (AF) is the most frequent type of cardiac arrhythmia. These
pathologies possess common risk factors, such as hypertension, diabetes mellitus, sleep
apnea, obesity and smoking. Moreover, inflammation is essential for the development of
both diseases. The prevalence of CAD in patients with AF ranges from 17 to 46.5%, while
the prevalence of AF in patients with CAD is relatively low and is estimated to be only 0.2–
5%. AF is a known factor of unfavorable short-term and long-term prognosis in patients
with acute myocardial infarction (AMI) and is associated with a significant increase in
overall mortality. Cardiac arrhythmias are not infrequent after cardiac surgery and occur in
approximately 30–40% of patients undergoing coronary artery bypass surgery. It is
estimated that 5–15% of patients with AF will ever require percutaneous coronary
intervention and, subsequently, triple antithrombotic therapy with aspirin, clopidogrel or
ticagrelor and oral anticoagulant. This demands a very careful consideration of balanced
antithrombotic therapy, taking into account the high risk of bleeding, the risk of stroke and
stent thrombosis with subsequent acute coronary syndrome. The concomitant administration
of oral anticoagulants with antiplatelet drugs, and, particularly, the triple therapy,
significantly increases the absolute risk of serious bleeding. In addition, heavy bleeding is
associated with a five-fold increase in the risk of an adverse outcome after acute coronary
syndrome. The co-presence of AF and CAD worsens the prognosis even in patients
undergoing thorough treatment.
Keywords:
coronary artery disease; atrial fibrillation; prevention; antithrombotic therapy.
Relevance
Atrial fibrillation is a cardiac arrhythmia that increases the risk of thrombus formation in
blood vessels. Ischemic heart disease (IHD), on the other hand, is associated with narrowing
or blockage of the coronary arteries, which impairs oxygen supply to the heart and can lead
to myocardial cell death. The coexistence of both conditions significantly affects the overall
health status of the patient.
Aim of the Study
To examine aspects of antiplatelet therapy in patients with atrial fibrillation and ischemic
heart disease.
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Research Results and Analysis
Ischemic heart disease (IHD) remains the most commonly diagnosed cardiovascular disorder
globally [1], while atrial fibrillation (AF) represents the leading type of cardiac rhythm
abnormality [2]. Among women, the occurrence of angina shows a marked increase with
age—from 5–7% in those aged 45–64 to 10–12% between 65–84 years. A similar trend is
seen in men, with prevalence rising from 4–7% to 12–14% across the same age ranges [3].
By 2013, IHD had become the foremost cause of mortality worldwide, with global deaths
escalating from 5.74 million in 1990 (accounting for 12% of the global population) to 8.14
million in 2013 (16.8%) [4].
Atrial fibrillation is estimated to affect around 2% of the population, with its prevalence
increasing notably with age—affecting 0.14% of individuals under 50 years, 4% of those
aged 60–70, and up to 14% among those over 80 [2,5]. Both IHD and AF share overlapping
risk factors such as hypertension, diabetes, obesity, sleep apnea, and tobacco use. Moreover,
systemic inflammation is recognized as a key contributor to the pathogenesis of both
conditions [6].
Among patients with AF, the proportion who also have IHD ranges between 17% and 46.5%
[7]. Findings from major clinical trials, including ROCKET-AF [8] and RE-LY [9], have
documented the presence of IHD in 17% of AF cases. According to a study by I.C. Van
Gelder and colleagues, 18% of patients with persistent AF were also diagnosed with IHD
[10]. Similarly, research by S. Kralev et al. identified significant coronary artery stenosis in
13% of AF patients undergoing coronary angiography, with the prevalence of sustained
arrhythmia being nearly equivalent in patients with and without IHD—30% and 27%,
respectively [11].
Conversely, atrial fibrillation appears to be less common among those diagnosed with IHD,
with estimates suggesting a prevalence of only 0.2% to 5% in this group [12].
Atrial Fibrillation and Myocardial Infarction
Atrial fibrillation (AF) frequently emerges as a complication following acute myocardial
infarction (AMI), with its incidence reported in 6–21% of affected individuals [13]. Notably,
approximately 10% of patients with a prior AMI already exhibit AF, while 25% of those
who experience an AMI go on to develop atrial fibrillation.A comprehensive study of 2,460
patients with documented myocardial infarction demonstrated that structural damage to the
atrial myocardium serves as an independent predictor of AF onset. This association persists
irrespective of other clinical variables such as age, gender, left ventricular ejection fraction,
left atrial volume, the timing of reperfusion therapy, or post-intervention coronary perfusion
assessed using the TIMI flow grading system [14].
Atrial Fibrillation as a Predictor of Short- and Long-Term Adverse Outcomes in Acute
Myocardial Infarction
Atrial fibrillation (AF) is recognized as a significant predictor of both short- and long-term
adverse outcomes in patients with acute myocardial infarction (AMI). Its presence is
strongly associated with increased overall mortality. Patients with a history of AMI and AF
have higher death rates compared to those without arrhythmia. Notably, around half of
newly diagnosed high atrial arrhythmias develop within the first month following an AMI.
The prognostic impact of AF varies; for instance, patients who develop AF within 30 days
of AMI face twice the risk of death compared to those without arrhythmia.A large-scale
study involving over 6,000 patients with AMI confirmed that new-onset AF is a common
and life-threatening complication. This arrhythmia not only increases the risk of mortality
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but also raises the likelihood of hospital readmission within 30 days. Additionally, patients
with both AMI and AF are twice as likely to experience acute cerebrovascular events during
hospitalization. These findings are consistent with data from the GRACE registry, which
demonstrated that in-hospital mortality is three times higher among patients who develop
new-onset AF during acute coronary syndrome. Moreover, these patients have nearly double
the incidence of heart failure and are three times more likely to suffer from cardiogenic
shock.
Mortality Risk Across Different AF Subtypes in AMI Patients and Potential
Mechanisms of Thrombotic Events
In a large single-center study involving 2,980 patients with acute myocardial infarction
(AMI), mortality outcomes were compared across different subtypes of atrial fibrillation
(AF). The results showed that only patients with permanent or new
-
onset AF had
significantly higher short- and long-term mortality rates compared to those without
arrhythmia. In contrast, patients with documented paroxysmal AF had the lowest 30-day
mortality rate among all AF subgroups—7.3%
,
which was close to the 5.2% observed in
patients without AF. However, over a 10-year follow-up period, overall mortality remained
elevated, though differences among subgroups were not statistically significant. In certain
cases, thromboembolic AMI has been reported in patients with AF [18]. This arrhythmia has
been linked to systemic inflammation
,
which may contribute to a prothrombotic state
,
ultimately precipitating myocardial infarction. Such inflammation could stem directly from
AF or from the underlying atherosclerotic risk factors commonly associated with the
arrhythmia.Other mechanisms may also explain the association between AF and AMI. For
instance, episodes of rapid ventricular response in AF can provoke Type II MI
,
which is
characterized by an imbalance between myocardial oxygen supply and demand, and
typically does not involve ST-segment elevation.Evidence from major randomized trials
supports these associations. In the ROCKET-AF study, AMI occurred in 101 patients (0.9%
annually) receiving rivaroxaban and in 126 patients (1.1% annually) treated with warfarin
[8]. Meanwhile, the RE-LY trial reported lower MI incidence rates: 0.53% per year in
patients taking warfarin and 0.72% per year in those receiving dabigatran 110 mg twice
daily [8].
References
1.
Bockeria, L.A., Yarbekov, R.R., Sigaev, I.Yu., Chigogidze, N.A., Merzlyakov, V.Yu.
and Keren, M.A. (2014). Comparison of long-term outcomes of coronary artery bypass
grafting and percutaneous coronary intervention using drug-eluting stents in patients with
multivessel coronary artery disease and diabetes mellitus.
Cardiovascular Diseases. Bulletin
of Bakoulev Center for Cardiovascular Surgery
, 15(5), pp.37–45.
(In Russian)
2.
Kirchhof, P., Benussi, S., Kotecha, D., Ahlsson, A., Atar, D., Casadei, B. et al.
(2016). 2016 ESC Guidelines for the management of atrial fibrillation developed in
collaboration with EACTS.
European Heart Journal
, 37(38), pp.2893–2962.
https://doi.org/10.1093/eurheartj/ehw210
3.
National Heart, Lung, and Blood Institute. (2012).
Morbidity and Mortality: 2012
Chart Book on Cardiovascular, Lung, and Blood Diseases
. Bethesda, MD.
4.
Naghavi, M., Wang, H., Lozano, R., Davis, A., Liang, X., Zhou, M. et al. (2015).
Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240
Vo
lu
m
e
5,
M
ay
,2
02
5
,
M
ED
IC
AL
SC
IE
N
CE
S.
IM
PA
CT
FA
CT
OR
:7
,8
9
causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study
2013.
The Lancet
, 385(9963), pp.117–171. https://doi.org/10.1016/S0140-6736(14)61682-2
5.
Bockeria, L.A. and Shengelia, L.D. (2014). Treatment of atrial fibrillation. Part II:
Current realities and future prospects.
Annals of Arrhythmology
, 11(2), pp.76–86.
https://doi.org/10.15275/annaritmol.2014.2.2
(In Russian)
6.
Bockeria, O.L., Akhobekov, A.A., Shvarts, V.A. and Kudzoeva, Z.F. (2015).
Efficacy of statins in primary prevention of atrial fibrillation in early postoperative period of
isolated coronary artery bypass grafting.
Annals of the Russian Academy of Medical
Sciences
, 70(3), pp.273–278. https://doi.org/10.15690/vramn.v70i3.1322
(In Russian)
7.
Hohnloser, S.H., Crijns, H.J., van Eickels, M., Gaudin, C., Page, R.L. and Torp-
Pedersen, C. et al. (2009). Effect of dronedarone on cardiovascular events in atrial
fibrillation.
New
England
Journal
of
Medicine
,
360(7),
pp.668–678.
https://doi.org/10.1056/NEJMoa0803778
8.
Patel, M.R., Mahaffey, K.W., Garg, J., Pan, G., Singer, D.E., Hacke, W. et al. (2011).
Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
New England Journal of
Medicine
, 365(10), pp.883–891. https://doi.org/10.1056/NEJMoa1009638
9.
Connolly, S.J., Ezekowitz, M.D., Yusuf, S., Eikelboom, J., Oldgren, J., Parekh, A. et
al. (2009). Dabigatran versus warfarin in patients with atrial fibrillation.
New England
Journal of Medicine
, 361(12), pp.1139–1151. https://doi.org/10.1056/NEJMoa0905561
10.
Van Gelder, I.C., Groenveld, H.F., Crijns, H.J., Tuininga, Y.S., Tijssen, J.G., Alings,
A.M. et al. (2010). Lenient versus strict rate control in patients with atrial fibrillation.
New
England
Journal
of
Medicine
,
362(15),
pp.1363–1373.
https://doi.org/10.1056/NEJMoa1001337
11.
Kralev, S., Schneider, K., Lang, S., Süselbeck, T. and Borggrefe, M. (2011).
Incidence and severity of coronary artery disease in patients with atrial fibrillation
undergoing
first-time
coronary
angiography.
PLoS
ONE
,
6(9),
e24964.
https://doi.org/10.1371/journal.pone.0024964
12.
Otterstad, J.E., Kirwan, B.A., Lubsen, J., De Brouwer, S., Fox, K.A., Corell, P.
and Poole-Wilson, P.A. (2006). Incidence and outcome of atrial fibrillation in stable
symptomatic coronary disease.
Scandinavian Cardiovascular Journal
, 40(3), pp.152–159.
https://doi.org/10.1080/14017430600746268
13.
Schmitt, J., Duray, G., Gersh, B.J. and Hohnloser, S.H. (2009). Atrial fibrillation
in acute myocardial infarction: a systematic review of the incidence, clinical features and
prognostic
implications.
European
Heart
Journal
,
30(9),
pp.1038–1045.
https://doi.org/10.1093/eurheartj/ehn579
14.
Jabre, P., Jouven, X., Adnet, F., Thabut, G., Bielinski, S.J., Weston, S.A. and
Roger, V.L. (2011). Atrial fibrillation and death after myocardial infarction: a community
study.
Circulation
,
123(19),
pp.2094–2100.
