Worsening of heart failure during hospital course of an unselected cohort of 2507 patients with myocardial infarction is a factor of poor prognosis: the PRIMA study. Prise en charge de l'Infarctus du Myocarde Aigu

Prediction Factors of 6-Month Poor Prognosis in Acute Myocardial Infarction Patients

Background: Acute myocardial infarction (AMI) is among the leading causes of death worldwide. Patients with AMI may have the risk of developing recurrent cardiovascular events leading to rehospitalization or even death. The present study aimed to investigate the prediction factors of poor prognosis (mortality and/or readmission) after AMI during a 6-month follow-up.

Methods: A total of 206 consecutive patients hospitalized for the first visit with AMI were enrolled. Data collection included demographic characteristics, medical history, clinical information, laboratory results, and oral medications within 24 h of admission. At 1, 3, and 6 months after discharge, AMI patients were followed up to assess the occurrence of composite endpoint events including in-hospital and out-of-hospital death and/or readmission due to recurrent myocardial infarction (MI) or exacerbated symptoms of heart failure following MI.

Results: After 6-month follow-up, a total of 197 AMI patients were available and divided in two groups according to good prognosis (n = 144) and poor prognosis (n = 53). Our data identified serum myoglobin ≥651 ng/mL, serum creatinine ≥96 μM, Killip classification 2–4, and female gender as independent predictors of 6-month mortality and/or readmission after AMI. Moreover, we demonstrated that Killip classification 2–4 combined with either myoglobin (AUC_{Killip class 2−4+myoglobin} = 0.784, sensitivity = 69.8%, specificity = 79.9%) or creatinine (AUC_{Killip class 2−4+creatinine} = 0.805, sensitivity = 75.5%, specificity = 77.1%) could further enhance the predictive capacity of poor 6-month prognosis among AMI patients.

Conclusions: Patients with AMI ranked in the higher Killip class need to be evaluated and monitored with attention. Multibiomarker approach using Killip classification 2–4 and myoglobin or creatinine may be an effective way for 6-month prognosis prediction in AMI patients.

Acute coronary syndromes complicated by symptomatic and asymptomatic heart failure: does current treatment comply with guidelines?

BACKGROUND

Patients with acute coronary syndromes (ACS) complicated by heart failure (HF) are at increased risk of death. Treatment with angiotensin-converting enzyme inhibitors (ACEI), beta-blockers, and early invasive risk stratification are recommended for these patients.

AIM

The purpose of the current study was to assess adherence to treatment guidelines of patients with ACS complicated by HF in Europe and the Mediterranean region.

METHODS AND RESULTS

Of the 10,484 patients who participated in Euro-Heart ACS survey, 9587 had known HF status and were without cardiogenic shock; 7058 (74%) did not have symptomatic HF and 2529 (26%) presented with or developed symptomatic HF during hospitalization. HF patients were older and had more cardiovascular risk factors. ACEI were more commonly used in HF patients (75% vs 56%, P < .01), whereas beta-blockers were less frequently used (75% vs 82%, P < .01). Coronary angiography and in hospital revascularization rates were lower among HF patients (42% vs 57% for coronary angiography, P < .01, and 32% vs 42% for revascularization, P < .01). Similar trends were noticed among patients with left ventricular dysfunction (symptomatic and asymptomatic).Adjusted in-hospital mortality risk was higher among patients with ACS complicated by symptomatic HF regardless of electrocardiographic type of ACS: (ST-elevation ACS, OR 2.5, 95% CI 1.6-3.9; non-ST-elevation ACS, OR 8.9,95% CI 4.5-17.7; undetermined-ECG ACS, OR 9.3, 95% CI 2.5-34).

CONCLUSIONS

Patients with ACS complicated by HF were at increased risk of dying. A relatively high percentage of HF patients were treated with ACEI and beta-blockers in accordance with current recommendations. Rates of coronary angiography and revascularization were significantly lower in ACS patients with HF versus those without HF, which potentially contributed to their worse mortality [corrected]

Heart failure in patients admitted to hospital: mortality is still high

BACKGROUND: Two separate cohorts of consecutive patients admitted to hospital with a primary diagnosis of heart failure were studied, the first in 1986 in Rochdale, and the second in 1995 in Brighton. METHODS: We observed the clinical profile, treatment and mortality during hospital admission and reviewed their status at 6 months. There were 132 patients in the Rochdale cohort and 223 in the Brighton cohort. RESULTS: The Rochdale cohort was characterised by a lower mean age and longer hospital stay. Significant differences were also observed in co-morbidity and the use of ACE inhibitors, but hospital mortality was almost identical (25% in Rochdale and 24% in Brighton). A low systolic blood pressure, hyponatraemia, hyperkalaemia and a raised blood urea at presentation were independent adverse prognostic factors. In contrast, prior treatment with ACE inhibitors in patients with congestive cardiac failure led to a more favourable hospital outcome. Age, gender and co-morbidity did not affect mortality apart from patients with acute myocardial infarction. Follow-up of these cohorts showed that mortality of the two groups remained high at 180 days after admission (40% in Rochdale and 39% in Brighton). There were marked differences in the use of ACE inhibitors in survivors, but target doses of ACE inhibitors (enalapril 20 mg/day or equivalent) were only achieved in 31%, despite direct communication between the hospital and primary care physicians. CONCLUSIONS: Although clinical and treatment profiles differed between the two periods studied, the hospital and 6-month mortality of patients with heart failure remained high. More emphasis needs to be given to optimising ACE inhibitor use in primary care.