Effect on survival of acute myocardial infarction in Killip classes II or III patients undergoing invasive coronary procedures

Unstable angina: trends and characteristics associated with length of hospitalization in the face of diminishing frequency-an evidence of a paradigm shift

Background

Unstable angina (UA) has been one of the most common presentations of acute coronary syndrome. The numbers of admitted UA patients have been diminishing in the recent past. However, we are seeing higher costs and higher length of inpatient stay. We attempt to identify the trends and characteristics of length of hospitalization in patients admitted with UA using a nationally representative dataset.

Methods

We used the nationwide inpatient sample (NIS) from 2002-2014 to assess the factors associated with length of stay in patients admitted with unstable angina using ICD-9-CM primary diagnosis codes (411.1, 411.81, and 411.89). All variables pertaining to hospitalization were compared across the 3 groups based on varied length of hospital stay.

Results

A total of 131,601 patients were admitted with the diagnosis of UA. The length of inpatient stay was ≤1 day, 2-6 days, and ≥7 days in 60,309 (45.83%), 67,291 (51.13%), and 4,001 (3.05%) patients, respectively. In a multivariate adjusted model, the percentage increased odds of ≥2 days of inpatient stay was noted as follows: age ≥65 years (29%), female gender(24%), African-American race (28%), obesity (14%), diabetes mellitus (15%), chronic lung disease (33%), congestive heart failure (529%), renal failure (26%), coagulopathy (68%), alcohol abuse (21%), peripheral vascular disease (22%), myocardial infarction (17%), deep vein thrombosis (119%), sepsis (105%), pneumonia (171%), stroke (164%), urinary tract infection (112%), blood loss (95%), cardiac catheterization (86%), percutaneous transluminal coronary angioplasty (24%), and blood transfusion (206%). The percentage of UA patients with ≥2 days of hospital stay has decreased from 15% to 3.7%, whereas the average costs of managing a UA patient in the hospital have increased by 175%.

Conclusions

More than half of patients admitted with UA stay in the hospital for ≥2 days, with the most important determinants being pre-existing medical comorbidities and inpatient complications.

Coronary artery bypass graft versus percutaneous coronary intervention in acute heart failure

Objective

Myocardial ischaemia is a leading cause of acute heart failure (AHF). However, optimal revascularisation strategies in AHF are unclear. We aimed to compare two revascularisation strategies, coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI), in patients with AHF.

Methods

Among 5625 consecutive patients enrolled prospectively in the Korean Acute Heart Failure registry from March 2011 to February 2014, 717 patients who received CABG or PCI during the index hospitalisation for AHF were included in this analysis. We compared adverse outcomes (death, rehospitalisation for HF aggravation or cardiovascular causes, ischaemic stroke and a composite outcome of death and rehospitalisation for HF aggravation or cardiovascular causes) with the use of propensity score matching.

Results

For the propensity score-matched cohort with 190 patients, CABG had a lower risk of all-cause mortality than PCI (83 vs 147 deaths per 1000 patient-years; HR 0.57, 95% CI 0.34 to 0.96, p=0.033) during the median follow-up of 4 years. There was also a trend towards lower rates of rehospitalisation due to cardiovascular events or HF aggravation. Subgroup analysis revealed that the adverse outcomes were significantly lower in the CABG group than in PCI group, especially in patients with old age, three-vessel diseases, significant proximal left anterior descending artery disease and those without left main vessel disease or chronic total occlusion.

Conclusions

Compared with PCI, CABG is associated with significant lower all-cause mortality in patients with AHF. Further studies should evaluate proper revascularisation strategies in AHF.

Clinical trial registration

NCT01389843; Results.

Early Invasive Strategy for Unstable Angina: a New Meta-Analysis of Old Clinical Trials

Randomized controlled trials (RCTs) were conflicting to support whether unstable angina versus non-ST-elevation myocardial infarction (UA/NSTEMI) patients best undergo early invasive or a conservative revascularization strategy. RCTs with cardiac biomarkers, in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from 1975-2013 were reviewed considering all cause mortality, recurrent non-fatal myocardial infarction (MI) and their combination. Follow-up lasted from 6-24 months and the use of routine invasive strategy up to its end was associated with a significantly lower composite of all-cause mortality and recurrent non-fatal MI (Relative Risk [RR] 0.79; 95% confidence interval [CI], 0.70-0.90) in UA/NSTEMI. In NSTEMI, by the invasive strategy, there was no benefit (RR 1.19; 95% CI, 1.03-1.38). In the shorter time period, from randomization to discharge, a routine invasive strategy was associated with significantly higher odds of the combined end-point among UA/NSTEMI (RR 1.29; 95% CI, 1.05-1.58) and NSTEMI (RR 1.82; 95% CI, 1.34-2.48) patients. Therefore, in trials recruiting a large number of UA patients, by routine invasive strategy the largest benefit was seen, whereas in NSTEMI patients death and non-fatal MI were not lowered. Routine invasive treatment in UA patients is accordingly supported by the present study.

Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era

BACKGROUND

People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI.

OBJECTIVES

To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era.

SEARCH METHODS

We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions.

SELECTION CRITERIA

We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI.

DATA COLLECTION AND ANALYSIS

Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables.

MAIN RESULTS

Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias.

AUTHORS' CONCLUSIONS

In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.

Diagnosis and management of acute heart failure

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Cardiogenic shock and heart failure post-percutaneous coronary intervention in ST-elevation myocardial infarction: observations from "Assessment of Pexelizumab in Acute Myocardial Infarction"

BACKGROUND

Mortality after ST-elevation myocardial infarction (STEMI) has reduced with reperfusion by primary percutaneous coronary intervention (PCI), which may have impacted on the adverse outcomes of cardiogenic shock (CS) and congestive heart failure (CHF).

METHODS AND RESULTS

In the APEX-AMI trial, 5,745 patients with STEMI and planned primary PCI were randomly assigned pexelizumab or matching placebo. Post-randomization CS or CHF was adjudicated by a clinical endpoints committee. Treatment assignment to pexelizumab did not influence either endpoint or mortality rates. Cardiogenic shock developed in 196 patients (3.4%) at a median of 6.0 hours (interquartile range 3.9-28.3) post-randomization, and mortality at 90 days was 54.6%. Congestive heart failure occurred in 254 of patients (4.4%) at a median of 2.6 days (IQR 1.0-16.6), and mortality through 90 days was 10.2%; mortality among those with neither endpoint was 2.1%. Patients with CS or CHF were older, were more often female, and had more hypertension and diabetes, but smoked less compared with non-CS/CHF patients (all P < .05). Independent mortality predictors among those with CS or CHF were hyperlipidemia and a history of angina (interaction P = .011 and .008, respectively); procedural predictors among survivors to PCI were pre-PCI Thrombolysis In Myocardial Infarction (TIMI) flow 0-1 and post-PCI TIMI flow <3 (P = .013 and <.0001, respectively).

CONCLUSIONS

Survival after CS remains poor despite aggressive reperfusion. Both CS and CHF remain the major causes of death among STEMI patients undergoing primary PCI. Future studies should examine treatments that aim to reduce mortality in these highest risk patients.

30-year trends in heart failure in patients hospitalized with acute myocardial infarction

Despite significant advances in its treatment, acute myocardial infarction (AMI) remains an important cause of heart failure (HF). Contemporary data remain lacking, however, describing long-term trends in incidence rates, demographic and clinical profiles, and outcomes of patients who develop HF as a complication of AMI. Our study sample consisted of 11,061 residents of the Worcester (Massachusetts) metropolitan area hospitalized with AMI at all greater Worcester hospitals in 15 annual study periods from 1975 to 2005. Overall, 32.4% of patients (n = 3,582) with AMI developed new-onset HF during their acute hospitalization. Patients who developed HF were generally older, more likely to have pre-existing cardiovascular disease, and were less likely to receive cardiac medications or undergo revascularization procedures during their hospitalization than patients who did not develop HF (p <0.001). Incidence rates of HF remained relatively stable from 1975 to 1991 at 26% but decreased thereafter. Decreases were also noted in hospital and 30-day death rates in patients with acute HF (p <0.001). However, patients who developed new-onset HF remained at significantly higher risk for dying during their hospitalization (21.6%) than patients who did not develop this complication (8.3%, p <0.001). Our large community-based study of patients hospitalized with AMI demonstrates that incidence rates of and mortality attributable to HF have decreased over the previous 3 decades. In conclusion, HF remains a common and frequently fatal complication of AMI to which increased surveillance and treatment efforts should be directed.

ACE gene insertion/deletion polymorphism has a mild influence on the acute development of left ventricular dysfunction in patients with ST elevation myocardial infarction treated with primary PCI

Background

We evaluated the associations among angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism, ACE activity and post-myocardial infarction (MI) left ventricular dysfunction and acute heart failure (AHF) early after presentation with MI with ST-segment elevation (STEMI).

Methods

A total of 556 patients with STEMI treated by primary PCI (421 patients without AHF and 135 patients with AHF) were the study population. The activity of BNP, NT-ProBNP and ACE were measured at hospital admission and 24 h after MI onset. Left ventricular angiography was done before PCI; echocardiography was undertaken between the third and fifth day after MI.

Results

In comparison with the II genotypes group, the DD/ID group had a higher level of ACE activity upon hospital admission (p < 0.001). We found a significantly higher level of ACE activity in patients with moderate LV dysfunction (EF 40-54%) in comparison both with patients with preserved LV function (EF ≥55%) and with patients with severe LV dysfunction (p = 0.028). A non-significant trend towards a higher incidence of mild AHF (22.1% vs. 16.02%, p = 0,093), a significantly higher value of end-systolic volume (ESV/BSA) (30.0 ± 12.3 vs. 28.5 ± 13.0; p < 0.05) and lower EF (50.2 ± 11.1 vs. 52.7 ± 11.7; p < 0.05) in the DD/ID genotypes group was noted. Even after multiple adjustments according to multivariate models, the EF for the DD/ID group remained significantly lower (p = 0,033). The DD/ID genotypes were associated with a significantly higher risk of EF <45% (OR 2.04 [95% CI 1.28; 3.25]).

Conclusions

These results suggest that the I/D polymorphism of ACE is associated with the development of LV dysfunction in the acute phase after STEMI. We demonstrated for the first time an association of the low ACE activity with the severe LV dysfunction, although patients with moderate LV dysfunction had higher level ACE activity than patients with preserved LV function.

Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era

BACKGROUND

In patients with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) two strategies are possible, either a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially, with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia.

OBJECTIVES

To determine the benefits of an invasive compared to conservative strategy for treating UA/NSTEMI in the stent era.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE and EMBASE were searched (1996 to February 2008) with no language restrictions.

SELECTION CRITERIA

Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI.

DATA COLLECTION AND ANALYSIS

We identified five studies (7818 participants). Using intention-to-treat analysis with random-effects models, summary estimates of relative risk (RR) with 95% confidence interval (CI) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction, all-cause death or non-fatal myocardial infarction, and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using Chi(2) and variance (I(2) statistic) methods.

MAIN RESULTS

In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy (RR 1.59, 95% CI 0.96 to 2.64). The invasive strategy did not reduce death on longer-term follow up. Myocardial infarction rates assessed at 6 to 12 months (5 trials) and 3 to 5 years (3 trials) were significantly decreased by an invasive strategy (RR 0.73, 95% CI 0.62 to 0.86; and RR 0.78, 95% CI 0.67 to 0.92 respectively). The incidence of early (< 4 month) and intermediate (6 to 12 month) refractory angina were both significantly decreased by an invasive strategy (RR 0.47, 95% CI 0.32 to 0.68; and RR 0.67, 95% CI 0.55 to 0.83 respectively), as were early and intermediate rehospitalization rates (RR 0.60, 95% CI 0.41to 0.88; and RR 0.67, 95% CI 0.61 to 0.74 respectively). The invasive strategy was associated with a two-fold increase in the RR of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the RR of (minor) bleeding with no hazard of stroke.

AUTHORS' CONCLUSIONS

Compared to a conservative strategy for UA/NSTEMI, an invasive strategy is associated with reduced rates of refractory angina and rehospitalization in the shorter term and myocardial infarction in the longer term. However, the invasive strategy is associated with a doubled risk of procedure-related heart attack and increased risk of bleeding and procedural biomarker leaks. Available data suggest that an invasive strategy may be particularly useful in those at high risk for recurrent events.

Influence of coronary angiography on the utilization of therapies in patients with acute heart failure syndromes: findings from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF)

BACKGROUND

Most patients hospitalized for acute heart failure syndromes (AHFS) carry a diagnosis of coronary artery disease (CAD), but coronary angiography is infrequently performed. This purpose of this study was to determine the influence of coronary angiography on use of therapeutics and early postdischarge outcomes in patients with AHFS.

METHODS

The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure program enrolled 48,612 patients admitted with AHFS at 259 academic and community hospitals throughout the United States Inhospital treatments and outcomes were tracked in all patients and postdischarge outcomes in a prespecified 10% sample. Outcome data were prospectively collected and analyzed according to whether coronary angiography was performed during the index hospitalization and whether a patient had CAD.

RESULTS

Overall, 8.7% of all patients underwent inhospital angiography. Among patients with CAD who underwent angiography, 27.5% underwent inhospital myocardial revascularization. At the time of discharge, patients with CAD who underwent angiography were significantly more likely to be receiving aspirin (68.9% vs 50.3%, P < .0001), statins (56.6% vs 40.6%, P < .0001), beta-blockers (78.6% vs 67.5%, P < .0001), and angiotensin-converting enzyme inhibitors (64.9% vs 51.5%, P < .0001). In patients with AHFS and CAD, the use of inhospital angiography was associated with significantly lower mortality and rehospitalization risk in the first 60 to 90 days post hospital discharge after adjustment for multiple comorbidities and patient factors: mortality (HR 0.31 [95% CI 0.14-0.70], P = .004) and death or rehospitalization (OR 0.65 [95% CI 0.50-0.86], P = .003). There were no significant differences in any of these outcomes in patients with AHFS and a nonischemic etiology based the performance of inhospital angiography.

CONCLUSIONS

The performance of inhospital angiography on patients with AHFS and CAD is associated with an increased use of aspirin, statins, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and myocardial revascularization. This corresponded with significantly lower rates of death, rehospitalization, and death or rehospitalization at 60 to 90 days post discharge.

Percutaneous coronary intervention for myocardial infarction with left ventricular dysfunction

Patients who have had a myocardial infarction (MI) are at high risk for developing left ventricular dysfunction (LVD), which predisposes them to heart failure and is associated with an increased mortality risk. Early coronary revascularization, either with percutaneous coronary intervention or coronary artery bypass graft surgery, plays an important role in the preservation and restoration of left ventricular function after MI. This article discusses the effects of primary and nonemergent percutaneous coronary revascularization procedures on survival, left ventricular function, and the occurrence of complications, such as recurrent MI and stroke, compared with the effects of thrombolytic therapy. In addition, this article describes rescue revascularization procedures for patients who failed thrombolysis and those presenting relatively late or with negative electrocardiographic findings. Advanced interventional techniques, such as percutaneous ventricular assist devices and bioabsorbable stents, are very promising and may potentially help improve the outcomes of post-MI patients with LVD; however, the use of these techniques requires further validation.

Do patients with heart failure appropriately undergo invasive procedures post-myocardial infarction? Results from a prospective multicentre study

BACKGROUND

The degree of adherence to guideline recommendations that patients following myocardial infarction (MI) with congestive heart failure (CHF) undergo early angiography, and angioplasty if indicated, is unknown.

METHODS

We prospectively evaluated the use of invasive procedures in patients with segment-elevation myocardial infarction (STEMI), non-STEMI and CHF, admitted in 1 month to 16 Australian hospitals.

RESULTS

Of 475 post-MI patients (248 (52.2%) with STEMI), 112 (23.6%) had CHF, (57 (23.0%) with STEMI). Patients with CHF, compared with those without CHF, were older (67.8 vs 63.2 years; P = 0.002) and were more often women (34 vs 24%, P = 0.03), but had similar rates of other risk factors. Compared with post-MI patients without CHF, patients with CHF had fewer invasive procedures: angiography 72.3% versus 85.1% (P = 0.002) and angioplasty 33.9% versus 52.9% (P < 0.001) (12 (2.5%) patients underwent coronary surgery in-hospital); and among STEMI patients (angiography 72.3% CHF vs 89.5% no CHF [P < 0.001]; angioplasty 50.9% CHF vs 69.1% no CHF [P = 0.011]); these differences remained significant after adjustment for clinical covariates. Of the 121 (25.5%) post-MI patients aged > or =75 years, compared with those <75 years, the frequencies of angiography and angioplasty procedures were 66.1% versus 87.6% (P < 0.001) and 33.9% versus 53.4% (P < 0.001), respectively; 66% of the elderly with, and without, CHF had angiography.

CONCLUSION

The presence of CHF post-MI resulted in lower rates of use of angiography and angioplasty, which was not explained by lower procedure rates in the elderly. As these guideline-recommended procedures may improve survival in patients with CHF post-MI, future strategies should aim to enhance their use.

Gender differences in mortality after acute myocardial infarction with mild to moderate heart failure

BACKGROUND

Heart failure (HF) is associated with poor outcome after acute myocardial infarction (AMI). Women have higher mortality rate than men after AMI, however, it is unknown whether women with HF after AMI have different prognosis than men.

AIM

To compare the prognosis of men and women with AMI and mild-moderate HF.

METHODS

We analyzed data of 3456 consecutive patients with AMI hospitalized in all cardiac care units in Israel during two nationwide surveys.

RESULTS

Among patients with AMI and HF on admission: women were older, had more risk factors, and were less likely to undergo percutaneous coronary angiography/intervention. Women with HF had higher (7-days, 30-days, and 1-year) crude mortality rates than men. However, adjusted mortality rates were not significantly different between genders.

CONCLUSIONS

Women with AMI complicated by HF had higher crude mortality rate than men that was eliminated after multivariate analysis, suggesting that the higher mortality rate may be attributed to increased prevalence of risk factors and lower rate of revascularization and medical therapies among women. Women with AMI and HF should be considered as a high-risk subgroup with adverse outcome. It remains to be determined whether more intensive management will improve their prognosis.

Prognostic significance of admission heart failure in patients with non-ST-elevation acute coronary syndromes (from the Canadian Acute Coronary Syndrome Registries)

We evaluated the in-hospital and 1-year outcomes and predictors of admission heart failure in patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs) without previous heart failure. We analyzed 4,825 patients with NSTE-ACS without a history of congestive heart failure who were included in the multicenter Canadian ACS Registries. Patients in Killip's class II/III on admission (n = 559, 11.6%) were compared with patients in Killip's class I. Patients with heart failure on admission were older (72 [64, 79] vs 64 [54, 73] years, p < 0.0001), with higher baseline creatinine levels (96 vs 88 mmol/dl, p <0.0001), more diabetes (32.2% vs 22.8%, p < 0.0001), hypertension (58% vs 52.4%, p = 0.014), previous myocardial infarction (MI; 38.9% vs 30.3%, p < 0.0001), previous stroke (13.5% vs 7.4%, p < 0.0001), and had more ST depression on admission (27.7% vs 17.3%, p < 0.0001). In-hospital treatment was similar except for a lower rate of aspirin therapy and fewer coronary interventions. Crude event rates were significantly higher in patients with heart failure (in-hospital death 3.6% vs 1.1%, p < 0.0001; death or MI 7.9% vs 4.7%, p = 0.0011; stroke 1.1% vs 0.4%, p = 0.03). One-year event rates were also higher in patients with heart failure (death 14.6% vs 4.4%, p < 0.0001; MI 9.3% vs 6.6%, p = 0.03; death or MI 21.5% vs 10.3%, p < 0.0001). Variables independently associated with heart failure were age (odds ratio 1.57, 95% confidence interval 1.43 to 1.73), diabetes mellitus (odds ratio 1.53, 95% confidence interval 1.24 to 1.89), admission ST depression (odds ratio 1.52, 95% confidence interval 1.22 to 1.90), previous MI, and baseline creatinine. Heart failure on admission was an independent predictor of in-hospital death, death or MI, and stroke and of 1-year death and death or MI. In conclusion, in patients with NSTE-ACS, heart failure on admission is associated with increased short- and long-term rates of death and MI.

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]

Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2)

OBJECTIVES

The purpose of this study was to examine treatment and outcomes in patients admitted to the hospital with acute myocardial infarction (AMI) complicated by congestive heart failure (CHF).

BACKGROUND

Although cardiogenic shock complicating AMI has been studied extensively, the hospital course of patients presenting with CHF is less well established.

METHODS

The Second National Registry of Myocardial Infarction (NRMI-2) was analyzed to determine hospital outcomes for patients with ST-elevation AMI admitted with CHF (Killip classes II or III).

RESULTS

Of 190,518 patients with AMI, 36,303 (19.1%) had CHF on admission. Patients presenting with CHF were older (72.6 +/- 12.5 vs. 63.2 +/- 13.5 years), more often female (46.8% vs. 32.1%), had longer time to hospital presentation (2.80 +/- 2.6 vs. 2.50 +/- 2.4 h), and had higher prevalence of anterior/septal AMI (38.8% vs. 33.3%), diabetes (33.1% vs. 19.5%), and hypertension (54.6% vs. 46.1%) (all p < 0.0005). Also, they had longer lengths of stay (8.1 +/- 7.1 vs. 6.8 +/- 5.3 days, p < 0.00005) and greater risk for in-hospital death (21.4% vs. 7.2%; p < 0.0005). Patients with CHF were less likely to receive aspirin (75.7% vs. 89.0%), heparin (74.6% vs. 91.1%), oral beta-blockers (27.0% vs. 41.7%), fibrinolytics (33.4% vs. 58.0%), or primary angioplasty (8.6% vs. 14.6%), and more likely to receive angiotensin-converting enzyme inhibitors (25.4% vs. 13.0%). Congestive heart failure on admission was one of the strongest predictors of in-hospital death (adjusted odds ratio 1.68; 95% confidence interval 1.62, 1.75).

CONCLUSIONS

Patients with AMI presenting with CHF are at higher risk for adverse in-hospital outcomes. Despite this, they are less likely to be treated with reperfusion therapy and medications with proven mortality benefit.