Selection of stent type in patients with atrial fibrillation presenting with acute myocardial infarction: An analysis from the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry-get with the guidelines

Background--Patients receiving oral anticoagulation in addition to dual-antiplatelet therapy are known to be at high risk for bleeding events; thus, the selection of a drug-eluting stent (DES) versus a bare metal stent (BMS) can have important implications for patients with atrial fibrillation (AF) presenting with acute myocardial infarction (MI). Methods and Results--From the National Cardiovascular Data Registry ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines, we identified 14 427 AF patients presenting with acute MI undergoing percutaneous coronary intervention from 2008 to 2014. Temporal trends and hospital variation in DES use were examined, as were patterns of use by stroke risk (CHA₂DS₂-VASc) and bleeding risk ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation). Among patients with linked Medicare data (n=2844), multivariable Cox regression modeling was used to compare risks for a composite outcome (all-cause mortality, readmission for stroke, or MI), readmission for stroke, revascularization, and major bleeding at 1 year. A DES was used in 8414 (58.9%) MI patients with AF, increasing from 47.1% in 2008 to 67.9% in 2014, with wide variation among hospitals. DES placement was more common than BMS placement among patients at high stroke risk (CHA₂DS₂-VASc ≥2) and high bleeding risk (ATRIA ≥4). Although aspirin and a P2Y₁₂ inhibitor were prescribed for > 95% of all patients regardless of stent type at discharge, warfarin was prescribed less frequently among patients receiving a DES than a BMS (31% versus 39%, P < 0.001). The composite outcome was similar between patients with a DES or BMS at 1 year (22% versus 26%; adjusted hazard ratio: 0.88; 95% confidence interval [CI], 0.76-1.03). Conclusions--Use of DESs among MI patients with AF has increased over time, but substantial hospital-level variation was observed. Patients with AF meeting indications for anticoagulation are more likely to receive a DES than a BMS, even among those at high predicted risk of both stroke and bleeding.