Coronaire embolie bij atriumfibrilleren: hoog rest-trombo-embolisch risico ondanks antistolling

BACKGROUND: Coronary embolism (CE) is an underrecognized cause of acute myocardial infarction (AMI) in patients with atrial fibrillation (AF). Dedicated management guidelines are lacking because of limited evidence. METHODS: This retrospective cohort study leveraged routinely collected electronic health records and regional death registry data from a tertiary hospital in China (2014-2023). Among 4777 patients with AMI, CE was diagnosed using a 3-stage validation process: modified Shibata criteria, blinded angiographic core laboratory assessment, and final adjudication. Patients were categorized into 3 groups: CE with AF (n=78), non-CE AMI with AF (n=205), and non-CE AMI without AF (n=3937). Overlap weighting based on propensity scores was used to balance baseline covariates, and weighted Cox proportional hazards models with competing-risk analysis were applied for comparative outcome analyses. RESULTS: CE accounted for 1.6% (95% CI, 1.3%-2.0%) of all AMI cases and was present in 14.7% to 27.6% of AF-related AMI. Compared with non-CE AMI patients without AF, those with CE and AF had significantly higher risks of all-cause mortality (overlap-weighted hazard ratio [HR], 1.77 [95% CI, 1.15-2.71]) and ischemic stroke (overlap-weighted HR, 4.45 [95% CI, 2.34-8.45]), despite 79.2% receiving therapeutic anticoagulation. CONCLUSIONS: CE complicating AF represents a high-risk phenotype characterized by high residual thromboembolic risk despite anticoagulation. An integrated management strategy is proposed for future investigation, incorporating multimodal imaging, embolism-targeted reperfusion, and optimization of antithrombotic therapy, including standard-dose direct oral anticoagulants. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT06845956.