Tatsuhiro Shibata1, Shoji Kawakami1, Teruo Noguchi2, Tomotaka Tanaka1, Yasuhide Asaumi1, Tomoaki Kanaya1, Toshiyuki Nagai1, Kazuhiro Nakao1, Masashi Fujino1, Kazuyuki Nagatsuka1, Hatsue Ishibashi-Ueda1, Kunihiro Nishimura1, Yoshihiro Miyamoto1, Kengo Kusano1, Toshihisa Anzai1, Yoichi Goto1, Hisao Ogawa1, Satoshi Yasuda1. 1. From Departments of Cardiovascular Medicine (T.S., S.K., T. Noguchi, Y.A., T.K., T. Nagai, K. Nakao, M.F., K.K., T.A., Y.G., H.O., S.Y.), Stroke and Cerebrovascular Disease (T.T., K. Nagatsuka), Pathology (H.I.-U.), and Preventive Medicine and Epidemiologic Informatics, Center for Cerebral and Cardiovascular Disease Information (K. Nishimura, Y.M.), National Cerebral and Cardiovascular Center, Suita, Japan. 2. From Departments of Cardiovascular Medicine (T.S., S.K., T. Noguchi, Y.A., T.K., T. Nagai, K. Nakao, M.F., K.K., T.A., Y.G., H.O., S.Y.), Stroke and Cerebrovascular Disease (T.T., K. Nagatsuka), Pathology (H.I.-U.), and Preventive Medicine and Epidemiologic Informatics, Center for Cerebral and Cardiovascular Disease Information (K. Nishimura, Y.M.), National Cerebral and Cardiovascular Center, Suita, Japan. tnoguchi@hsp.ncvc.go.jp.
Abstract
BACKGROUND: Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of acute myocardial infarction. Its prevalence, clinical features, and prognosis remain insufficiently characterized. METHODS AND RESULTS: We screened 1776 consecutive patients who presented with de novo acute myocardial infarction between 2001 and 2013. CE was diagnosed based on criteria encompassing histological, angiographic, and other diagnostic imaging findings. The prevalence, clinical characteristics, treatment strategies, in-hospital outcomes, and long-term risk of CE recurrence or major adverse cardiac and cerebrovascular events (cardiac death, fatal arrhythmia, or recurrent thromboembolism) were evaluated. The prevalence of CE was 2.9% (n=52), including 8 (15%) patients with multivessel CE. Atrial fibrillation was the most common cause (n=38, 73%). Only 39% of patients with CE were treated with vitamin K antagonists, and the median international normalized ratio was 1.42 (range, 0.95-1.80). Eighteen of the 30 CE patients with nonvalvular atrial fibrillation had a CHADS2 score of 0 or 1. When those patients were reevaluated using CHA2DS2-VASc, 61% were reassigned to a higher risk category. During a median follow-up of 49 months, CE and thromboembolism recurred in 5 atrial fibrillation patients. The 5-year rate of major adverse cardiac and cerebrovascular events was 27.1%. In the propensity score-matched cohorts (n=45 each), Kaplan-Meier analysis showed a significantly higher incidence of cardiac death in the CE group than in the non-CE group (hazard ratio, 9.29; 95% confidence interval, 1.13-76.5; P<0.001). CONCLUSIONS: Atrial fibrillation is the most frequent cause of CE. Patients with CE represent a high-risk subgroup of patients with acute myocardial infarction and require close follow-up.
BACKGROUND:Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of acute myocardial infarction. Its prevalence, clinical features, and prognosis remain insufficiently characterized. METHODS AND RESULTS: We screened 1776 consecutive patients who presented with de novo acute myocardial infarction between 2001 and 2013. CE was diagnosed based on criteria encompassing histological, angiographic, and other diagnostic imaging findings. The prevalence, clinical characteristics, treatment strategies, in-hospital outcomes, and long-term risk of CE recurrence or major adverse cardiac and cerebrovascular events (cardiac death, fatal arrhythmia, or recurrent thromboembolism) were evaluated. The prevalence of CE was 2.9% (n=52), including 8 (15%) patients with multivessel CE. Atrial fibrillation was the most common cause (n=38, 73%). Only 39% of patients with CE were treated with vitamin K antagonists, and the median international normalized ratio was 1.42 (range, 0.95-1.80). Eighteen of the 30 CE patients with nonvalvular atrial fibrillation had a CHADS2 score of 0 or 1. When those patients were reevaluated using CHA2DS2-VASc, 61% were reassigned to a higher risk category. During a median follow-up of 49 months, CE and thromboembolism recurred in 5 atrial fibrillationpatients. The 5-year rate of major adverse cardiac and cerebrovascular events was 27.1%. In the propensity score-matched cohorts (n=45 each), Kaplan-Meier analysis showed a significantly higher incidence of cardiac death in the CE group than in the non-CE group (hazard ratio, 9.29; 95% confidence interval, 1.13-76.5; P<0.001). CONCLUSIONS:Atrial fibrillation is the most frequent cause of CE. Patients with CE represent a high-risk subgroup of patients with acute myocardial infarction and require close follow-up.