Importancia de la carga vascular previa en la mortalidad intrahospitalaria y a largo plazo de pacientes con infarto de miocardio y segmento ST elevado

Prognostic Impact of Previous Atherosclerotic Cardiovascular Disease on Short- and Long-Term Outcomes in Acute Myocardial Infarction

Patients with previous atherosclerotic cardiovascular disease (ASCVD) are typically managed by secondary prevention modalities; however, they may experience recurrent events. In acute myocardial infarction (MI), the prognostic effect of preexisting ASCVD on the short- and long-term outcomes remains uncertain. This retrospective, multicenter registry included 2,475 patients with acute MI who underwent percutaneous coronary intervention. Previous ASCVD was defined as a history of ischemic events in the coronary, cerebral, and peripheral arterial territories. Patients were divided into 2 groups according to preexisting ASCVD. The primary end point was major adverse cardiovascular events (MACEs), defined as a composite of cardiovascular death, recurrent MI, and ischemic stroke during hospitalization and after discharge. The bleeding outcomes were also evaluated. Of the 2,475 patients, 475 (19.2%) had previous ASCVD. Patients with previous ASCVD were older and likely to have more co-morbidities than those without ASCVD. During hospitalization, the MACE rates were higher in the ASCVD group than in the non-ASCVD group (16.4% vs 9.6%, p <0.001). Similarly, during a median follow-up of 542 days after discharge, patients with previous ASCVD had an increased risk of MACEs than those without ASCVD (13.4% vs 5.6%, p <0.001). The multivariable analyses identified previous ASCVD as a factor that was significantly associated with MACEs after discharge. Major bleeding events occurred more frequently in the ASCVD group than in the non-ASCVD group. In conclusion, preexisting ASCVD was often observed in patients with acute MI and was particularly associated with long-term ischemic outcomes after discharge; thus, further clinical investigations are needed in this vulnerable patient subset.

Albuminuria and polyvascular disease improve multivariate predictive models after an acute cardiovascular event. The AIRVAG cohort

BACKGROUND AND AIMS

There is no consensus regarding risk stratification tools for secondary prevention in atherosclerotic cardiovascular disease. Our aim was to compare the discriminative performance of the Framingham, REGICOR, SCORE, and REACH risk functions and the Bohula-TIMI and SMART risk scores, as well as to assess the potential added value of other clinical variables for the prediction of recurrent events in patients with established vascular disease.

METHODS

A cohort of 269 patients with established vascular disease (52.8% coronary, 32% cerebrovascular, 15.2% PAD) was included. The survival functions of risk groups (low/medium/high) according to commonly used cutoff points for each function/score were compared, and hazard ratios for each were estimated using Cox regression. We calculated Δ Harrell's C statistic, cat-NRI, and cNRI after adding new predictors to a base model including age, sex, total cholesterol, current smoking status, hypertension, and diabetes.

RESULTS

After six years of follow-up (median 4.82 years), 61 events occurred (23%). High-risk groups had a higher risk of recurrent event: SMART (HR: 3.17 [1.55-6.5]), Framingham (HR: 3.08 [1.65-5.75]), REGICOR (HR: 2.71 [1.39-5.27]), SCORE (HR: 2.14 [1.01-4.5], REACH (HR: 5.74 [2.83-11.7]), B-TIMI (HR: 3.68 [0.88-15.3]). Polyvascular disease (three territories HR: 5.6 [2.2-14.25]), albuminuria (HR: 3.55 [2.06-6.11]), and heart failure (HR: 3.11 [1.34-7.25]) also increased risk. Discrimination (Harrell's C) was low but improved after adding albuminuria and polyvascular disease. Both variables also improved the performance of the base model (cNRI.326 [.036; .607]).

CONCLUSIONS

The Framingham, REGICOR, SCORE, and REACH functions and the B-TIMI and SMART scores showed low yet similar performance in secondary prevention. Albuminuria and polyvascular disease improved the predictive performance of major classical cardiovascular risk factors.

Outcome of Patients With Prior Stroke/Transient Ischemic Attack and Acute Coronary Syndromes

The association between prior stroke/transient ischemic attack (TIA) and clinical outcomes in patients with acute coronary syndrome (ACS) has not been well explored. We evaluated the impact of prior stroke/TIA on this specific patient population. We conducted an international multicenter study including 15 401 patients with ACS from the Bleeding Complications in a Multicenter Registry of Patients Discharged With Diagnosis of Acute Coronary Syndrome registry. They were divided into 2 groups: patients with and without prior stroke/TIA. The primary end point was death at 1-year follow-up. Prior stroke/TIA was associated with higher rate of 1-year death (8.7% vs 3.4%; P < .001). It was an independent predictor of 1-year death even after adjustment for confounding variables (odds ratio, 1.705; 95% confidence interval, 1.046-2.778; P = .032). Besides, patients with prior stroke/TIA had significantly increased 1-year reinfarction (5.6% vs 3.8%, P = .015), in-hospital bleeding (8.7% vs 5.8%, P < .001), and 1-year bleeding (5.2% vs 3.0%, P < .001). No difference of antithrombotic therapies or dual antiplatelet therapy (DAPT) types on outcomes was observed in patients with prior stroke/TIA. Prior stroke/TIA was associated with higher 1-year death for patients with ACS who underwent percutaneous coronary intervention. No benefits or harms were observed with different antithrombotic therapies or DAPT types in these patients.

Short-term prognostic effect of prior cerebrovascular and peripheral artery disease in patients with acute coronary syndrome: Can we do better?

BACKGROUND

We sought to evaluate the impact of prior cerebrovascular and/or peripheral arterial disease (PAD) on in-hospital outcomes in patients with acute coronary syndromes.

METHODS

From 1 October 2010 to 26 February 2016, 13,904 acute coronary syndrome patients were enrolled in a national multicentre registry. They were divided into four groups: prior stroke/transient ischaemic attack (stroke/TIA); prior PAD; prior stroke/TIA and PAD; none. The endpoints included in-hospital mortality and a composite endpoint of death, re-infarction and stroke during hospitalization.

RESULTS

6.3% patients had prior stroke/TIA, 4.2% prior PAD and 1.4% prior stroke/TIA and PAD. Prior stroke/TIA and/or PAD patients were less likely to receive evidence-based medical therapies (dual antiplatelet therapy: stroke/TIA= 88.6%, PAD= 86.6%, stroke/TIA+PAD= 85.7%, none= 92.2%, p<0.001; β-blockers: stroke/TIA= 77.1%, PAD= 72.1%, stroke/TIA+PAD= 71.9%, none= 80.8%, p<0.001; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers: stroke/TIA= 86.3%, PAD= 83.6%, stroke/TIA+PAD= 83.2%, none= 87.1%, p=0.030) and to undergo percutaneous revascularization (stroke/TIA= 52.8%, PAD= 45.6%, stroke/TIA+PAD= 43.7%, none= 67.9%, p<0.001), despite more extensive coronary artery disease (three-vessel disease: stroke/TIA= 29.1%, PAD= 38.3%, stroke/TIA+PAD= 38.3%, none= 20.2%, p<0.001). In a multivariable analysis, prior stroke/TIA+PAD was a predictor of in-hospital mortality (odds ratio= 2.828, 95% confidence interval 1.001-7.990) and prior stroke/TIA (odds ratio= 1.529, 95% confidence interval 1.056-2.211), prior PAD (odds ratio= 1.618, 95% confidence interval 1.034-2.533) and both conditions (odds ratio= 3.736, 95% confidence interval 2.002-6.974) were associated with the composite endpoint.

CONCLUSION

A prior history of stroke/TIA and/or PAD was associated with lower use of medical therapy and coronary revascularization and with worst short-term prognosis. An individualized management may improve their poor prognosis.

Endothelial Dysfunction After ST-segment Elevation Myocardial Infarction and Long-term Outcome: A Study With Reactive Hyperemia Peripheral Artery Tonometry

INTRODUCTION AND OBJECTIVES

Long-term data on the relationship between endothelial dysfunction after ST-segment elevation myocardial infarction and future adverse clinical events are scarce. The aim of this study was to noninvasively assess whether endothelial dysfunction 4 weeks to 6 weeks after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction predicts future clinical events.

METHODS

This prospective cohort study was performed in 70 patients of the RESPONSE randomized trial, who underwent noninvasive assessment of endothelial function 4 weeks to 6 weeks after primary percutaneous coronary intervention. Endothelial function was measured by the reactive hyperemia peripheral artery tonometry method; an index<1.67 identified endothelial dysfunction.

RESULTS

The reactive hyperemia peripheral artery tonometry index measured on average 1.90±0.58. A total of 35 (50%) patients had endothelial dysfunction and 35 (50%) patients had normal endothelial function. Periprocedural "complications" (eg, cardiogenic shock, total atrioventricular block) were more common in patients with endothelial dysfunction than in those without (25.7% vs 2.9%; P<.01). During 4.0±1.7 years of follow-up, 20 (28.6%) patients had major adverse cardiovascular events: events occurred in 9 (25.7%) patients with endothelial dysfunction and in 11 (31.5%) patients with normal endothelial function (P=.52). There was an association between the prevalence of diabetes mellitus at baseline and the occurrence of major adverse cardiovascular events during follow-up (univariate analysis: hazard ratio=2.8; 95% confidence interval, 1.0-7.8; P<.05), and even in multivariate analyses the risk appeared to be increased, although not significantly (multivariate analysis: hazard ratio=2.5; 95% confidence interval, 0.8-7.5).

CONCLUSIONS

In this series of patients who survived an ST-segment elevation myocardial infarction, endothelial dysfunction, as assessed by reactive hyperemia peripheral artery tonometry 4 weeks to 6 weeks after myocardial infarction, did not predict future clinical events during a mean follow-up of 4 years.

Coronary Artery Dominance and Long-term Prognosis in Patients With ST-segment Elevation Myocardial Infarction Treated With Primary Angioplasty

INTRODUCTION AND OBJECTIVES

The long-term prognostic significance of coronary artery dominance pattern in patients with ST-segment elevation myocardial infarction is poorly characterized. We investigated the prognosis of such patients according to whether they had right dominance, left dominance, or codominance.

METHODS

This was a retrospective study of 767 patients, who were admitted to hospital between 2007 and 2012 with ST-segment elevation myocardial infarction and treated with primary percutaneous coronary intervention. We determined the effect of the coronary dominance pattern on all-cause mortality and readmission for infarction, adjusting for mortality as a competing event.

RESULTS

A total of 80.9% of patients had right coronary dominance, and 8.6% had left coronary dominance. Over 40.8 months' [interquartile range, 21.9-58.3 months] follow-up, 118 (15.4%) deaths were recorded, of which 39 (5.1%) were in hospital. Mortality for right dominance, left dominance, and codominance was 7.1%, 36.4%, and 13.8% (P ˂ .001), respectively. Cause of death was cardiovascular in 7.1%, 21.2%, and 2.4%. On Cox multivariate analysis, left dominance was significantly associated with mortality (hazard ratio = 1.76; P = .02). Taking "coronary dominance" into account in prediction of risk of death improved the discrimination and calibration capacity of GRACE (Global Registry of Acute Coronary Events) scoring. At follow-up, 9.3% (71 patients) had reinfarction. On multivariate analysis, left dominance was an independent predictor of reinfarction (subhazard ratio = 2.06; P = .01).

CONCLUSIONS

In ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, left coronary artery dominance confers a higher risk of death and reinfarction than right coronary artery dominance, and should be included in prognostic stratification.

Does marital status contribute to the explanation of the hypercholesterolemia paradox in relation to long term mortality in myocardial infarction? Findings from the MONICA/KORA Myocardial Infarction Registry

OBJECTIVE

A recent study found long-term mortality after first acute myocardial infarction (AMI) to be particularly reduced among married individuals with hypercholesterolemia. This study explores, whether statin treatments during the last week prior to AMI offer an explanation to this phenomenon.

METHODS

Data were retrieved 2000-2008 from the population-based KORA myocardial infarction registry, located in Bavaria, Germany. The sample included 3162 individuals, alive 28days after first AMI, who received statins both in hospital and at discharge. Associations with long-term mortality were examined via multivariable Cox regression. Among patients with hypercholesterolemia, individuals with and without prior statin treatment were each tested against the reference group "neither (hypercholesterolemia nor statin)" and tested for interaction with "marital status".

RESULTS

Among patients with and without prior statins, hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.46-0.93 and HR 0.72, 95% CI 0.55-0.94, were observed, respectively. Mortality reductions diminished after introduction of the following interaction terms with marital status: HR 0.49, p 0.042 for patients with and HR 0.77, p 0.370, for patients without prior statins.

CONCLUSIONS

Prior statin treatments appear to be an underlying factor for long-term mortality reduction in married AMI-survivors with hypercholesterolemia. Confirmation of our results in further studies is warranted.

Educational Level and Long-term Mortality in Patients With Acute Myocardial Infarction

INTRODUCTION AND OBJECTIVES

The value of socioeconomic status as a prognostic marker in acute myocardial infarction is controversial. The aim of this study was to evaluate the impact of educational level, as a marker of socioeconomic status, on the prognosis of long-term survival after acute myocardial infarction.

METHODS

We conducted a prospective, observational study of 5797 patients admitted to hospital with acute myocardial infarction. We studied long-term all-cause mortality (median 8.5 years) using adjusted regression models.

RESULTS

We found that 73.1% of patients had primary school education (n=4240), 14.5% had secondary school education (including high school) (n=843), 7.0% was illiterate (n=407), and 5.3% had higher education (n=307). Patients with secondary school or higher education were significantly younger, more were male, and they had fewer risk factors and comorbidity. These patients arrived sooner at hospital and had less severe heart failure. During admission they received more reperfusion therapy and their crude mortality was lower. Their drug treatment in hospital and at discharge followed guideline recommendations more closely. On multivariate analysis, secondary school or higher education was an independent predictor and protective factor for long-term mortality (hazard ratio=0.85; 95% confidence interval, 0.74-0.98).

CONCLUSIONS

Our study shows an inverse and independent relationship between educational level and long-term mortality in patients with acute myocardial infarction.