Association between admission supine systolic blood pressure and 1-year mortality in patients admitted to the intensive care unit for acute chest pain

Role of ambulatory blood pressure on prediction of cardiovascular disease. A cohort study

Ambulatory blood pressure (BP) is associated with mortality, but it is also interesting to expand its association with cardiovascular morbidity. This study sought to evaluate association with cardiovascular morbidity and cardiovascular mortality. Patients without cardiovascular disease who had a first 24-hour ambulatory BP monitoring were followed-up until the onset of the first event (a combined variable of cardiovascular mortality, coronary heart disease, cerebrovascular disease, peripheral arteriopathy, or hospital admission for heart failure). Changes in antihypertensive treatment couldn't be collected. Cox regression analysis was adjusted for risk factors and office BP. We included 3907 patients (mean age, 58.0, SD 13.8 years), of whom 85.5% were hypertensive. The follow up period was 6.6 (95% CI 5.0-8.5) years. A total of 496 (12.7%) events were recorded. The incidence rate was 19.3 (95% CI 17.7-21.1) cases per 1000 person-years. The patients with an event compared to the rest of patients were mostly men, older, with higher office and ambulatory systolic BP, higher prevalence of diabetes, chronic kidney disease, dyslipidemia, and non-dipper or riser circadian profile. In the fully adjusted model, office BP loses its significant association with the main variable. Ambulatory BP association remained significant with cardiovascular morbidity and mortality, HR 1.494 (1.326-1.685) and 0.767 (0.654-0.899) for 24-hour systolic and diastolic BP, respectively. Nighttime systolic BP also maintained this significant association, 1.270 (1.016-1.587). We conclude that nighttime systolic BP and 24-hour BP are significantly associated with cardiovascular events and cardiovascular mortality in patients without cardiovascular disease attended under conditions of routine clinical practice.

Risk Factors for Arrhythmic Death, Overall Mortality, and Ventricular Tachyarrhythmias Requiring Shock After Myocardial Infarction

The VEST (Vest Prevention of Early Sudden Death Trial) showed a trend toward decreased sudden death and lower overall mortality with a wearable cardioverter-defibrillator (WCD) in the postmyocardial infarction (post-MI) period. However, it is unclear which patients should receive WCD therapy. We aimed to identify the risk factors for arrhythmic death, all-cause mortality, and ventricular tachyarrhythmias requiring appropriate shock to identify patients most likely to benefit from a WCD. The VEST trial included patients with acute MI with ejection fraction ≤35%. Using logistic regression, 7 risk factors were evaluated for association with arrhythmic death, all-cause mortality, and appropriate shock. Among 2,302 participants, 44 had arrhythmic death (1.9%) and 86 died of any cause (3.7%). Among 1,524 participants randomized to WCD, 20 experienced appropriate shock (1.3%) over 90 days. In the multivariable analyses, lower systolic blood pressure (SBP; odds ratio [OR] 1.64 per 10 mm Hg) and higher heart rate at discharge (OR 1.19 per 10 beats/min) were associated with arrhythmic death. Lower SBP (OR 1.37) and higher heart rate (OR 1.10) were associated with all-cause mortality. Higher heart rate (OR 1.20) was associated with appropriate shock. Patients with both SBP ≤100 and heart rate ≥100 were at increased odds of arrhythmic death (OR 4.82), all-cause mortality (OR 3.10), and appropriate shock (OR 6.13). In patients with acute MI and reduced ejection fraction, lower SBP and higher heart rate at discharge were strongly associated with arrhythmic death and all-cause mortality. In conclusion, these risk factors identify a select group at high risk of adverse events in a setting where WCD therapy is reasonable.

J-curve relationship between admission SBP and 2-year cardiovascular mortality in older patients admitted for acute coronary syndrome

OBJECTIVE

To investigate the relationship between admission SBP and subsequent cardiovascular and all-cause mortality in older patients hospitalized for acute coronary syndrome (ACS).

METHODS

This is a retrospective observational study. Data from the CBD Bank (Cardiovascular Center Beijing Friendship Hospital Database Bank) were used to analyze the cardiovascular and all-cause mortality during hospitalization and over the follow-up period in relation to admission SBP among patients aged at least 65 years admitted for ACS from December 2012 through July 2019. Results were presented according to SBP quartiles: Q1, less than 120 mmHg; Q2, from 120 to 129 mmHg; Q3, from 130 to 143 mmHg; and Q4, at or above 144 mmHg.

RESULTS

A total of 6785 patients were included in this cohort study. Mean (SD) patient age was 74.0 (6.5) years, and 47.6% were women. Mean (SD) follow-up time was 2.54 (1.82) years. A nonlinear relation was observed between SBP at admission and cardiovascular and all-cause mortality during hospitalization and over the follow-up period using restricted cubic splines. After adjustment for potential confounders, patients in Q1 had higher risk for 2-year cardiovascular death by Cox proportional hazard model compared with patients in Q2 [hazard ratio, 1.58; 95% confidence interval (CI), 1.12-2.21, P = 0.009], whereas patients in Q3 or Q4 exhibited a trend towards increased risk for 2-year cardiovascular death (hazard ratio, 1.33, 95% CI, 0.95-1.86, P = 0.094, for Q3 vs. Q2; and hazard ratio, 1.28, 95% CI, 0.91-1.82, P = 0.160, for Q4 vs. Q2). Meanwhile, when compared with patients in Q1, patients in Q2 had lower risk for 2-year cardiovascular death (hazard ratio, 0.64; 95% CI, 0.45-0.89, P = 0.009) whereas patients in Q3 or Q4 had similar risk for cardiovascular death (hazard ratio, 0.85, 95% CI, 0.63-1.14, P = 0.272, for Q3 vs. Q1; and hazard ratio, 0.82, 95% CI, 0.59-1.13, P = 0.221, for Q4 vs. Q1). However, low-admission SBP was not an independent predictor of 2-year all-cause mortality in this population.

CONCLUSION

Among patients aged at least 65 years admitted for ACS, there is a J-curve relationship between supine admission SBP and risk for 2-year cardiovascular death, with a nadir at 120-129 mmHg.

Low admission blood pressure as a marker of poor 1-year survival in patients with revascularized critical limb ischemia

OBJECTIVE

To contrast the association between blood pressure (BP) level and antihypertensive medications at hospital admission with 1-year mortality in patients undergoing revascularization for critical limb ischemia (CLI).

METHODS

From November 2013 to May 2019, 315 consecutive patients were retrospectively included. A median of seven (IQR 3-13) separate readings were recorded for each patient before revascularization procedure and the average represented patient's mean BP. BP-lowering medications, clinical and biological parameters were recorded at baseline. The main outcome was total 1-year mortality.

RESULTS

The cohort included 172 men (55%) and 143 women (45%), with a mean age of 77.9 ± 11.9 years. Treated hypertension was present in 245 (78%) patients; 288 (91%) patients had BP-lowering drug prescriptions (2.1 ± 1.3 medications at baseline). Mean SBP, DBP, mean BP (MBP) and pulse pressure (PP) were 132 ± 18, 70 ± 8, 90 ± 10 and 62 ± 16mmHg. During 1-year follow-up, 80 (25.4%) patients died. In single-pressure multivariate analysis, SBP (hazard ratio 0.97; 95% CI 0.96-0.99; P = 0.005), MBP (hazard ratio 0.96; 95% CI 0.92-0.99; P = 0.01), PP (hazard ratio 0.97; 95% CI 0.95-0.99; P = 0.009), but not DBP, were inversely correlated with 1-year mortality, independently of age, coronary heart disease, left ventricular ejection fraction, brain natriuretic peptide, serum albumin, institutionalized status and antihypertensive drugs. Association between SBP, MBP and PP with 1-year mortality had a quite linear reverse pattern.

CONCLUSION

Among patients undergoing revascularization for CLI, there is an inverse correlation between admission SBP, MBP and PP with 1-year mortality. BP may represent a modifiable therapeutic target to prevent poor outcome in CLI patients.

Outcome and selection of revascularization strategy in left main coronary artery stenosis

OBJECTIVES

To investigate clinical outcome in unselected real-life patients with unprotected left main coronary artery (ULMCA) stenosis and determine factors associated with selection of revascularization strategy.

DESIGN

Consecutive patients with ULMCA stenosis at our institution in 2009-2013 (n = 308) were retrospectively analyzed with propensity score adjusted Cox proportional hazards models for outcome. Baseline characteristics in relation to selection of revascularization strategy were analyzed with multivariate logistic regression.

RESULTS

Patients that underwent PCI (n = 94) had a higher risk of major adverse cardiac and cerebrovascular events (MACCE; adjusted HR 2.13 [95% CI 1.08-4.19]) than patients that had CABG surgery but there was no difference in the combination of death and MI (adjusted HR 1.17 [95% CI 0.50-2.75]). Later year of index angiography, age, Euroscore II and angiographer favoring PCI was associated with PCI as revascularization strategy. Higher SYNTAX score, higher systolic blood pressure and angiographer favoring CABG was associated with CABG.

CONCLUSIONS

In consecutive patients with ULMCA stenosis PCI is associated with higher MACCE rates than CABG but there is no difference in death and MI. Later year of index angiography, higher age, lower systolic blood pressure, higher predicted per-procedural surgical risk, less complex coronary anatomy and angiographer favoring PCI increased the probability of revascularization with PCI instead of CABG.

Asking the Patient or Measuring Blood Pressure in the Emergency Department: Which One is Best?

Blood pressure (BP) is obtained at the emergency department (ED) in the vast majority of patients; irrespective of chief complaint, and elevated BP, above the threshold for hypertension, is a common observation. In this review, we address the predictive value of measured BP in the ED compared to that of a history of hypertension in patients with chief complaints related to cardiovascular disease. In chest pain patients, a high BP at the ED is associated to a good prognosis, whereas the history of hypertension is associated to a poor prognosis. In heart failure, a high admission BP is consistently linked to a good prognosis, whereas the clinical value of history of hypertension in the ED is unknown. In stroke, there is a U-shaped relation between admission BP and outcome. A history of hypertension is common among stroke patients but does not seem to provide any predictive value in the ED.

Personalising the decision for prolonged dual antiplatelet therapy: development, validation and potential impact of prognostic models for cardiovascular events and bleeding in myocardial infarction survivors

Aims

The aim of this study is to develop models to aid the decision to prolong dual antiplatelet therapy (DAPT) that requires balancing an individual patient's potential benefits and harms.

Methods and results

Using population-based electronic health records (EHRs) (CALIBER, England, 2000-10), of patients evaluated 1 year after acute myocardial infarction (MI), we developed (n = 12 694 patients) and validated (n = 5613) prognostic models for cardiovascular (cardiovascular death, MI or stroke) events and three different bleeding endpoints. We applied trial effect estimates to determine potential benefits and harms of DAPT and the net clinical benefit of individuals. Prognostic models for cardiovascular events (c-index: 0.75 (95% CI: 0.74, 0.77)) and bleeding (c index 0.72 (95% CI: 0.67, 0.77)) were well calibrated: 3-year risk of cardiovascular events was 16.5% overall (5.2% in the lowest- and 46.7% in the highest-risk individuals), while for major bleeding, it was 1.7% (0.3% in the lowest- and 5.4% in the highest-risk patients). For every 10 000 patients treated per year, we estimated 249 (95% CI: 228, 269) cardiovascular events prevented and 134 (95% CI: 87, 181) major bleeding events caused in the highest-risk patients, and 28 (95% CI: 19, 37) cardiovascular events prevented and 9 (95% CI: 0, 20) major bleeding events caused in the lowest-risk patients. There was a net clinical benefit of prolonged DAPT in 63-99% patients depending on how benefits and harms were weighted.

Conclusion

Prognostic models for cardiovascular events and bleeding using population-based EHRs may help to personalise decisions for prolonged DAPT 1-year following acute MI.

Secondary prevention strategies after an acute ST-segment elevation myocardial infarction in the AMI code era: beyond myocardial mechanical reperfusion

BACKGROUND

The AMI code is a regional network enhancing a rapid and widespread access to reperfusion therapy (giving priority to primary angioplasty) in patients with acute ST-segment elevation myocardial infarction (STEMI). We aimed to assess the long-term control of conventional cardiovascular risk factors after a STEMI among patients included in the AMI code registry.

DESIGN AND METHODS

Four hundred and fifty-four patients were prospectively included between June-2009 and April-2013. Clinical characteristics were collected at baseline. The long-term control of cardiovascular risk factors and cardiovascular morbidity/mortality was assessed among the 6-months survivors.

RESULTS

A total of 423 patients overcame the first 6 months after the STEMI episode, of whom 370 (87%) underwent reperfusion therapy (363, 98% of them, with primary angioplasty). At 1-year follow-up, only 263 (62%) had adequate blood pressure control, 123 (29%) had LDL-cholesterol within targeted levels, 126/210 (60%) smokers had withdrawn from their habit and 40/112 (36%) diabetic patients had adequate glycosylated hemoglobin levels. During a median follow-up of 20 (11-30) months, cumulative mortality of 6 month-survivors was 6.1%, with 9.9% of hospital cardiovascular readmissions. The lack of assessment of LDL and HDL-cholesterol were significantly associated with higher mortality and cardiovascular readmission rates.

CONCLUSIONS

Whereas implementation of the AMI code resulted in a widespread access to rapid reperfusion therapy, its long-term therapeutic benefit may be partially counterbalanced by a manifestly suboptimal control of cardiovascular risk factors. Further efforts should be devoted to secondary prevention strategies after STEMI.

Blood pressure and all-cause mortality: a prospective study of nursing home residents

AIM

to explore the natural course of blood pressure development and its relation to mortality in a nursing home cohort.

METHODS

a cohort of 406 nursing home residents in south east Sweden was followed prospectively for 30 months. Participants were divided into four groups based on systolic blood pressure (SBP) at baseline. Data were analysed using a Cox regression model with all-cause mortality as the outcome measurement; paired Student t-tests were used to evaluate blood pressure development over time.

RESULTS

during follow-up, 174 (43%) people died. Participants with SBP < 120 mmHg had a hazard ratio for mortality of 1.56 (95% confidence interval, 1.08-2.27) compared with those with SBP 120-139 mmHg, adjusted for age and sex. Risk of malnutrition or present malnutrition was most common in participants with SBP < 120 mmHg; risk of malnutrition or present malnutrition estimated using the Mini Nutritional Assessment was found in 78 (71%). The levels of SBP decreased over time independent of changes in anti-hypertensive medication.

CONCLUSIONS

in this cohort of nursing home residents, low SBP was associated with increased all-cause mortality. SBP decreased over time; this was not associated with altered anti-hypertensive treatment. The clinical implication from this study is that there is a need for systematic drug reviews in elderly persons in nursing homes, paying special attention to those with low SBP.

Comparison of 4 Admission Blood Pressure Indexes for Predicting 30-Day Mortality in Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND

We compared admission systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) in predicting 30-day all-cause mortality in patients with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock.

METHODS

A retrospective study was performed in 7,033 consecutive STEMI patients. Multivariate-adjusted hazard ratios (HRs) with a 10mm Hg increment and quartiles of each blood pressure were determined by Cox proportional hazard analyses; Wald χ (2) tests were used to compare the strength of relationships.

RESULTS

Totally 593 (8.4%) patients died during follow-up. Of 4 indexes, only SBP (HR 0.94 per 10mm Hg, 95% confidence interval (CI) 0.91 to 0.98; P = 0.001) and PP (HR 0.89 per 10 mmHg, 95% CI 0.85 to 0.94; P < 0.001) were significantly associated with 30-day all-cause mortality; these in the highest vs. lowest quartiles of SBP (≥140 vs. <110mm Hg) and PP (≥60 vs. <40mm Hg) had HRs of mortality of 0.70 (95% CI 0.55 to 0.87; P = 0.003) and 0.60 (95% CI 0.47 to 0.75; P < 0.001), respectively. Compared with SBP, PP was a better predictor for mortality no matter in men (χ (2) = 5.9 for per 10mm Hg, χ (2) = 10.8 for quartiles) or women (χ (2) = 15.1 for per 10mm Hg, χ (2) = 19.5 for quartiles), and the relationship remained significant after adjustment of SBP. There was a pattern of declining risk with increasing blood pressures for mortality, and this trend was mainly observed in age groups of more than 70 years.

CONCLUSIONS

Pulse pressure was an independent predictor of mortality in patients with STEMI, and low admission blood pressure should serve as a warning sign.

Admission blood pressure and 1-year mortality in acute myocardial infarction

AIMS

Arterial hypertension is a well-established factor for increased risk of cardiovascular diseases, but low admission blood pressure has also been suggested as predictor for increased mortality. We hypothesised that in patients with acute myocardial infarction admission blood pressure at the Emergency Department predicts long-term mortality.

METHODS

We included consecutive patients treated for acute myocardial infarction (AMI) at our 2,200-bed tertiary care hospital from 1991 to 2009 into our cohort. Systolic, diastolic and pulse pressure on admission were analysed as main predictors for 1-year mortality. We adjusted for several baseline factors and tested for interactions using multivariable regression models.

RESULTS

We included 3943 patients among whom 3604 were alive after 1 year. With increasing admission blood pressure 1-year mortality risk decreased incrementally to a 70% reduced relative risk in the highest blood pressure categories vs. the lowest categories. This effect was independent of blood pressure modifying interventions.

CONCLUSIONS

In acute myocardial infarction, admission blood pressure predicts long-term mortality in an inverse relation. With increasing admission blood pressure long-term mortality decreases. Low admission blood pressure should serve as a warning sign in patients with AMI. Admission blood pressure should therefore be interpreted in opposite to the regular, preventive, point of view.

Clinical characteristics and short-term outcomes in patients with elevated admission systolic blood pressure after acute ST-elevation myocardial infarction: a population-based study

OBJECTIVE

Prognostic value of lower admission systolic blood pressure (SBP) in patients with acute myocardial infarction has been confirmed, but the impact of elevated admission SBP on short-term outcomes has been evaluated only by a limited number of studies and they have reported conflicting results. The aim of our study was to investigate the characteristics and short-term outcomes in patients with elevated admission SBP after ST-elevation myocardial infarction (STEMI).

DESIGN

A population-based, observational study.

SETTING

The multicentre registry in China.

PARTICIPANTS

A total of 7510 consecutive patients with STEMI were registered. Patients were divided into three groups according to admission SBP: normal admission SBP (100-139 mm Hg), modestly elevated admission SBP (140-179 mm Hg) and excessively elevated admission SBP (≥180 mm Hg). The primary outcomes were 7-day and 30-day all-cause mortality, major adverse cardiac events (MACE) and bleeding rate.

RESULTS

Of 6591 patients, 4182 (63.5%) had normal admission SBP, 2187 (33.2%) modestly elevated admission SBP and 222 (3.4%) excessively elevated admission SBP. Patients with elevated admission SBP had a high-risk profile, such as were more likely to be older, with more concomitant cardiovascular morbidities, presenting with more events of anterior myocardial infarction and less reperfusion treatment. However, 7-day and 30-day all-cause mortality, MACE and bleeding rate were comparable among groups (all p>0.05). Survival curves and MACE curves were similar among groups (p=0.377 and 0.375, respectively). After multivariate adjustment, elevated admission SBP was not associated with increased risk of short-term death and bleeding, and MACE was comparable with normal admission SBP.

CONCLUSIONS

Although those with elevated admission SBP after STEMI were at a higher risk for cardiovascular events, they did not have poorer short-term outcomes compared with patients with normal admission SBP.

Prognostic impact of early ventricular fibrillation in patients with ST-elevation myocardial infarction treated with primary PCI

AIMS

Current guidelines do not advocate implantation of cardioverter-defibrillators (ICD) for survivors of ventricular fibrillation (VF) during the first 48 hours of ST-elevation myocardial infarction (STEMI). However, contemporary studies in a real-life setting with long-term follow-up are lacking. We assessed the prognostic impact of early VF in a non-selected population of STEMI patients treated with primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Consecutive STEMI patients admitted to a Swedish tertiary care hospital during 2007-2009 were identified from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (n=1718, age 66±12 years, 70% male). Patients with VF were identified from the register, and medical records were reviewed to determine the time point of VF. Patients surviving VF in the first 48 hours after symptom onset were compared with patients without VF for one-year mortality and a combined endpoint of death, resuscitated VF or appropriate ICD therapy. VF within 48 hours occurred in 7% of STEMI patients (n=121). In patients alive at 48 hours (n=1663), VF patients (n=101) had higher in-hospital mortality (12% vs. 2%, p<0.001). However, in VF patients discharged alive (n=89), mortality was low (1%) and combined endpoint rate (3%) did not differ compared with patients without VF (n=1538; 4% and 4% respectively).

CONCLUSION

In a large non-selected population of STEMI patients treated with primary PCI, VF during the first 48 hours after STEMI is associated with increased in-hospital mortality but does not influence the long-term prognosis for those discharged alive.

Survival after hospital discharge for ST-segment elevation and non-ST-segment elevation acute myocardial infarction: a population-based study

Background

Limited recent data are available describing differences in long-term survival, and factors affecting prognosis, after ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), especially from the more generalizable perspective of a population-based investigation. The objectives of this study were to examine differences in post-discharge prognosis after hospitalization for STEMI and NSTEMI, with a particular focus on factors associated with reduced long-term survival.

Methods

We reviewed the medical records of residents of the Worcester, MA, USA metropolitan area hospitalized at eleven central Massachusetts medical centers for acute myocardial infarction (AMI) during 2001, 2003, 2005, and 2007.

Results

A total of 3762 persons were hospitalized with confirmed AMI; of these, 2539 patients (67.5%) were diagnosed with NSTEMI. The average age of study patients was 70.3 years and 42.9% were women. Patients with NSTEMI experienced higher post-discharge death rates with 3-month, 1-year, and 2-year death rates of 12.6%, 23.5%, and 33.2%, respectively, compared to 6.1%, 11.5%, and 16.4% for patients with STEMI. After multivariable adjustment, patients with NSTEMI were significantly more likely to have died after hospital discharge (adjusted hazards ratio 1.28; 95% confidence interval 1.14–1.44). Several demographic (eg, older age) and clinical (eg, history of stroke) factors were associated with reduced long-term survival in patients with NSTEMI and STEMI.

Conclusions

The results of this study in residents of central Massachusetts suggest that patients with NSTEMI are at higher risk for dying after hospital discharge, and several subgroups are at particularly increased risk.

Hypertension and acute myocardial infarction: an overview

History of hypertension is a frequent finding in patients with acute myocardial infarction (AMI) and its recurring association with female sex, diabetes, older age, less frequent smoking and more frequent vascular comorbidities composes a risk profile quite distinctive from the normotensive ischemic counterpart.Antecedent hypertension associates with higher rates of death and morbid events both during the early and long-term course of AMI, particularly if complicated by left ventricular dysfunction and/or congestive heart failure. Renin-angiotensin-aldosterone system blockade, through either angiotensin-converting enzyme inhibition, angiotensin II receptor blockade or aldosterone antagonism, exerts particular benefits in that high-risk hypertensive subgroup.In contrast to the negative implications carried by antecedent hypertension, higher systolic pressure at the onset of chest pain associates with lower mortality within 1 year from coronary occlusion, whereas increased blood pressure recorded after hemodynamic stabilization from the acute ischemic event bears inconsistent relationships with recurring coronary events in the long-term follow-up.Whether antihypertensive treatment in post-AMI hypertensive patients prevents ischemic relapses is uncertain. As a matter of fact, excessive diastolic pressure drops may jeopardize coronary perfusion and predispose to new acute coronary events, although the precise cause-effect mechanisms underlying this phenomenon need further evaluation.

How Safe Is the Outpatient Management of Patients with Acute Chest Pain and Mildly Increased Cardiac Troponin Concentrations?

BACKGROUND

The appropriate management of patients discharged from the emergency department (ED) with increased high-sensitivity cardiac troponin T (hs-cTnT) but normal or borderline-high conventional cardiac troponin concentrations is unknown.

METHODS

We investigated 643 consecutive ED patients with acute chest pain who had been discharged for outpatient management after acute myocardial infarction (AMI) had been ruled out by serial measurements of conventional cardiac troponin. hs-cTnT was measured blindly, and we calculated the rates of all-cause mortality (primary endpoint) and subsequent AMI (secondary endpoint) at 30, 90, and 360 days.

RESULTS

hs-cTnT concentrations were increased (&gt;14 ng/L) in 114 patients (18%) but &lt;30 ng/L in 95% of these patients. Of those 114 patients, 96 (84%) had an adjudicated noncoronary cause of chest pain. Thirty-day mortality (95% CI) was 0.9% (0.1%–6.1%), 90-day mortality was 2.7% (0.9%–8.1%), and 360-day mortality was 5.2% (2.2%–11.9%) in patients with increased hs-cTnT; respective rates (95% CI) of AMI were 0.0%, 1.9% (0.5%–7.2%), and 7.6% (3.7%–15.3%). Increased hs-cTnT was associated with increased mortality and AMI at 90 days (P = 0.006 and P = 0.081, respectively) and 360 days (P = 0.001 for both).

CONCLUSIONS

hs-cTnT is a strong prognosticator of intermediate and long-term mortality and AMI in low-risk patients discharged from the ED after AMI has been ruled out. The relatively low rate of 30-day events may suggest that patients without acute coronary syndrome and small increases in cardiac troponin are in need of further investigations and treatments, but not necessarily immediate hospitalization.

Systolic blood pressure at Emergency Department presentation and 1-year mortality in acute chest pain patients

BACKGROUND

High blood pressure at rest has been an established risk factor for cardiovascular disease. However the relationship between Systolic Blood Pressure (SBP) and 1-year-mortality among acute chest pain patients presenting to Emergency Department (ED); and effects of preexisting renal insufficiency, hemodynamic stress - as quantified by Brain Natriuretic Peptide (BNP) and chest pain duration, on this relationship is unknown.

METHODS

Data was used from APACE (Advantageous Predictors of Acute Coronary Syndrome Evaluation), a prospective observational multicenter study of 1240 ED chest pain patients. SBP at presentation was categorized into quartiles: Q1≤127mmHg; Q2 128-142mmHg; Q3 143-160mmHg; Q4≥161mmHg.

RESULTS

60 deaths occurred during 1-year. One-year-mortality-rate showed lower Hazard Ratios for Q2, Q3 and Q4 vs Q1 (HR [95% CI]; 0.39 (0.19-0.78), 0.34 (0.17-0.70), 0.35 (0.17-0.72); p<0.01 respectively). Cox model adjusted for various demographic and treatment variables showed that participants in Q3 and Q4 had better prognoses than Q1. Patients showed progressively better prognosis from Q2 through Q4 vs Q1 only in patients who presented to ED with for more than 12h of chest pain duration. Patients with renal insufficiency had lower SBP at presentation than others (p=0.001). There was no association between the outcome and interaction variable of SBP quartiles and BNP (p=0.27).

CONCLUSION

Acute chest pain patients presenting to ED exhibit an inverse association between SBP at presentation and 1-year-mortality; a relationship which appears stronger in those who present with chest pain of greater than 12h duration.