Objective: For patients with atrial fibrillation (AF) complicated with acute coronary syndrome (ACS), both anticoagulant and antiplatelet therapy should be applied, but the use of anticoagulation therapy is still poor in these patients in China. The purpose of this study was to explore the status and adherence of antithrombotic therapy in AF patients with ACS and the impact on 1 year clinical outcomes. Methods: Patients with AF hospitalized for ACS were retrospectively included from 6 tertiary hospitals in China between July 2015 and December 2020. According to the use of anticoagulant drugs at discharge, patients were divided into two groups: anticoagulant treatment group and non-anticoagulant treatment group. Logistic regression model was used to analyze the main factors influencing the use of anticoagulant drugs in patients with atrial fibrillation complicated with ACS. Major adverse cardiac events (MACEs) were defined as all-cause death, non-fatal myocardial infarction or coronary revascularization, and ischemic stroke and Bleeding Academic Research Consortium (BARC) 3 bleeding events were also collected at 1 year after discharge. After propensity score matching, Cox proportional hazards models and Kaplan-Meier analysis were used to evaluate the effect of anticoagulant treatment and non-anticoagulant treatment on 1-year prognosis. The patients were divided into different groups according to whether anticoagulation was performed at discharge and follow-up, and the sensitivity of the results was analyzed. Results: A total of 664 patients were enrolled, and 273 (41.1%) were treated with anticoagulant therapy, of whom 84 (30.8%) received triple antithrombotic therapy, 91 (33.3%) received double antithrombotic therapy (single antiplatelet combined with anticoagulant), and 98 (35.9%) received single anticoagulant therapy. Three hundred and ninety-one (58.9%) patients were treated with antiplatelet therapy, including 253 (64.7%) with dual antiplatelet therapy and 138 (35.3%) with single antiplatelet therapy. After 1∶1 propensity score matching between the anticoagulant group and the non-anticoagulant group, a total of 218 pairs were matched. Multivariate logistic regression analysis showed that history of diabetes, HAS-BLED score≥3, and percutaneous coronary intervention were predictors of the absence of anticoagulant therapy, while history of ischemic stroke and persistent atrial fibrillation were predictors of anticoagulant therapy. At 1-year follow-up, 218 patients (79.9%) in the anticoagulant group continued to receive anticoagulant therapy, and 333 patients (85.2%) in the antiplatelet group continued to receive antiplatelet therapy. At 1-year follow-up, 36 MACEs events (13.2%) occurred in the anticoagulant group, and 81 MACEs events (20.7%) in the non-anticoagulant group. HR values and confidence intervals were calculated by Cox proportional risk model. Patients in the non-anticoagulant group faced a higher risk of MACEs (HR=1.802, 95%CI 1.112-2.921, P=0.017), and the risk of bleeding events was similar between the two group (HR=0.825,95%CI 0.397-1.715, P=0.607). Conclusions: History of diabetes, HAS-BLED score≥3, and percutaneous coronary intervention are independent factors for the absence of anticoagulant therapy in patients with AF complicated with ACS. The incidence of MACEs, death and myocardial infarction is lower in the anticoagulant group, and the incidence of bleeding events is similar between the two groups. The risk of bleeding and ischemia/thrombosis should be dynamically assessed during follow-up and antithrombotic regiments should be adjusted accordingly.
目的： 描述心房颤动（房颤）合并急性冠脉综合征（ACS）患者1年内抗栓治疗的现状和依从性以及抗凝治疗对1年预后的影响。 方法： 该研究为多中心回顾性队列研究，纳入2015年7月至2020年12月全国6家三级医院的房颤合并ACS住院患者。根据患者出院时抗栓治疗情况，分为抗凝治疗组和非抗凝治疗组。随访出院后1年的主要不良心血管事件（MACEs），包括全因死亡、非致死性心肌梗死或再次冠状动脉血运重建、缺血性卒中以及出血学术研究联合会（BARC）3型出血。采用logistic回归模型分析房颤合并ACS患者抗凝药物使用的影响因素。采用倾向得分匹配进行1∶1匹配，通过Cox比例风险模型、Kaplan-Meier曲线评价抗凝治疗和非抗凝治疗对1年预后的影响。根据出院及随访时抗凝情况分组，对结果进行敏感性分析。 结果： 共纳入664例房颤合并ACS患者，273例（41.1%）患者接受抗凝治疗，其中84例（30.8%）患者接受三联抗栓治疗，91例（33.3%）患者接受双联抗栓治疗（单一抗血小板联合抗凝药物），98例（35.9%）患者为单一抗凝治疗。共有391例（58.9%）患者仅行抗血小板治疗，其中253例（64.7%）为双联抗血小板治疗，138例（35.3%）为单一抗血小板治疗。经过抗凝治疗组与非抗凝治疗组1∶1倾向得分匹配后，共匹配到218对。多因素logistic回归分析发现，糖尿病病史、HAS-BLED评分≥3分和接受经皮冠状动脉介入治疗治疗是未抗凝治疗的独立影响因素，而缺血性卒中病史、持续性房颤是患者使用抗凝药物的独立影响因素。随访1年，抗凝治疗组中仍有218例患者（79.9%）继续进行抗凝治疗，抗血小板治疗组中仍有333例患者（85.2%）继续进行抗血小板治疗。抗凝治疗组共发生MACEs事件36例（13.2%），非抗凝治疗组共发生MACEs事件81例（20.7%）。通过Cox比例风险模型计算，发现非抗凝治疗组MACEs（HR=1.802，95%CI：1.112~2.921，P=0.017）发生风险较高，而出血事件风险并不低（HR=0.825，95%CI：0.397~1.715，P=0.607）。 结论： 糖尿病病史、HAS-BLED评分≥3分和接受经皮冠状动脉介入治疗治疗是房颤合并ACS患者不使用抗凝治疗的独立影响因素；抗凝治疗组MACEs、全因死亡、心肌梗死事件发生率较低，且并未增加出血事件。合并ACS的房颤患者应动态评估血栓和出血风险，个体化调整抗栓方案。.