Highlights
- •
Many patients with ST-elevation myocardial infarction still develop heart failure.
- •
Incident heart failure significantly increases mortality.
- •
Well-established predictors only explain a small fraction of that risk.
ST-elevation myocardial infarction (STEMI) survivors have a heightened risk of developing heart failure (HF). The magnitude of this risk with the advent of primary percutaneous coronary intervention is less characterized. We aimed to examine the incidence and predictors of incident HF and all-cause mortality in a contemporary STEMI cohort. We performed a retrospective analysis of 700 consecutive patients with STEMI treated with primary percutaneous coronary intervention at a tertiary hospital. The primary outcome was the occurrence of HF during follow-up. HF was defined by HF hospitalization or the presence of congestion that led to de novo prescription or up-titration of diuretics in the outpatient clinic. The secondary outcome was defined by the occurrence of HF or all-cause mortality. During a median follow-up period of 43.6 months, HF events occurred in 110 patients (15.7%), 34 (4.8%) managed as outpatient and 76 (10.9%) requiring hospitalization. Left ventricular ejection fraction (LVEF) <50% was present in 76% of those who developed HF. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01 to 1.06), diabetes (HR 1.85, 95% CI 1.12 to 3.05), door-to-balloon time (HR 1.002, 95% CI 1.000 to 1.003), Killip-Kimball class ≥II (HR 2.24, 95% CI 1.32 to 3.80) and LVEF <50% (HR 1.71, 95% CI 1.01 to 2.92) were independent predictors. All-cause mortality incidence was 8.7%. HF was independently associated with a threefold increased risk of dying (HR 3.52, 95% CI 1.85 to 6.69, p <0.001). In conclusion, a substantial proportion of contemporary patients with STEMI develop HF, which triplicates the risk of dying. Older age, diabetes and LVEF <50% independently predicted the development of HF and all-cause death.
Heart failure (HF) is a major public health concern worldwide reaching a prevalence of 1% to 2% of the adult population, rising to more than 10% among people with more than 70 years in developed countries. HF is also associated with significant morbimortality characterized by annual hospitalization and all-cause mortality rates of 10% to 44% and 6% to 24%, respectively. , Ischemic heart disease is one of the main causes of HF. The widespread use of primary percutaneous coronary intervention (PCI) had significantly improved the prognosis of patients with ST-elevation myocardial infarction (STEMI). STEMI contemporary reports show that in-hospital mortality rates fell from 12% to 4%. This improvement of the acute survival rates made long-term cardiovascular complications 1 of the current great challenges. Several studies report an incidence of HF after STEMI between 4% and 28%. This wide range is explained by the high variability in reperfusion therapy, the diverse definitions of HF, and the different populations studied. The characterization of the overall incidence of HF and the identification of the high-risk profiles is critical to improving the management of the patients with post-STEMI. In this study, we aimed to determine the incidence and predictors of HF and all-cause mortality of a contemporary cohort of patients with STEMI.
Methods
We conducted a retrospective single-center study of consecutive patients with STEMI submitted to primary PCI in a tertiary academic hospital (Centro Hospitalar Universitário do Porto, Porto, Portugal) between 2010 and 2016.
STEMI was defined according to the Fourth Universal Definition of Myocardial Infarction. The treatment approach of all patients followed the recommendations of the European Society of Cardiology guidelines. Exclusion criteria were the previous diagnosis of HF, rescue PCI after use of fibrinolytic agents, death during index hospitalization, and incomplete follow-up defined by the absence of any clinical data after index hospitalization discharge. All data of demographic, clinical, laboratory, and echocardiographic parameters were collected by review of electronic health records.
All baseline clinical characteristics were collected from index STEMI hospitalization. Left ventricular ejection fraction (LVEF) was calculated by echocardiographic biplane Simpson’s method in patients with acceptable acoustic window or eyeballing, according to European Association of Cardiovascular Imaging recommendations. Estimated glomerular filtration rate was calculated using the Cockcroft-Gault formula.
The primary outcome was defined as the occurrence of HF during follow-up. HF was defined either by a (1) HF hospitalization or (2) the worsening of the patient’s symptoms or signs of congestion that led to de novo prescription or up-titration of diuretics by an assistant physician in the outpatient clinic. The secondary outcome was defined by the occurrence of HF or all-cause death during follow-up. They were all assessed by electronic health record review. LVEF data near HF event was obtained from the contemporary echocardiography report if available.
Statistical analysis was conducted using IBM SPSS Statistics for Windows (version 24.0. IBM Corp, Armonk, New York). Independent Student’s t test and Mann-Whitney U test were used to compare normally and non-normally distributed continuous variables, respectively. Categorical variables were compared by chi-square or Fisher’s exact tests. Independent predictors of the outcomes were assessed using Cox models. We adjusted the Cox proportional hazard models for variables with a p <0.1 in univariate analysis. The predictive value of the models was analyzed using logistic regression. The Kaplan-Meier method was used to estimate the survival curves. All tests were two-sided and p <0.05 was considered to be statistically significant.
The study was approved by the Ethics Committee of Centro Hospitalar Universitário do Porto and conducted in accordance with the Declaration of Helsinki.
Results
During the study period, 864 patients were admitted to our hospital with the diagnosis of STEMI and submitted to primary PCI. Of these, we excluded 164 patients: 39 had a previous diagnosis of HF, 67 died during STEMI hospitalization and 58 had incomplete follow-up ( Supplementary Table 1 ). The remaining 700 patients were included in our analysis. During a median follow-up period of 43.6 (interquartile range [IQR] 26.7 to 66.7) months, the primary outcome occurred in 110 (15.7%) patients.
Baseline characteristics of the overall population are displayed in Table 1 . The mean age was 61.1 ± 12.6 years and 538 (76.9%) were male. The primary outcome was significantly associated with older age, female gender, higher body mass index, hypertension, diabetes, and peripheral artery disease. Patients with incident HF also had increased total ischemic time and door-to-balloon time. At presentation, they were more frequently in Killip-Kimball (KK) class ≥II. At hospital admission, they had lower values of hemoglobin and worse renal function. Culprit lesion was more commonly located in the left anterior descendent artery and peak troponin level was higher. At hospital discharge, LVEF was lower in patients who developed HF but the prescription of β-blockers and angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers were not different.
| Baseline characteristics | Overall (n=700) | Primary outcome (n=110) | No primary outcome (n=590) | p value |
|---|---|---|---|---|
| Age (years), mean (SD) | 61.1 (12.6) | 68.7 (12.2) | 59.6 (12.2) | <0.001 |
| Men | 538 (76.9%) | 71 (64.5%) | 467 (79.2%) | 0.001 |
| BMI (Kg/m 2 ), mean (SD) | 26.4 (3.7) | 27.3 (4.3) | 26.2 (3.6) | 0.01 |
| Hypertension | 372 (53.3%) | 77 (70.0%) | 295 (50.2%) | <0.001 |
| Dyslipidemia | 395 (56.8%) | 65 (59.1%) | 330 (56.3%) | 0.33 |
| Diabetes mellitus | 158 (22.6%) | 43 (39.1%) | 115 (19.6%) | <0.001 |
| Insulin-treated | 25 (3.6%) | 10 (9.1%) | 15 (2.6%) | 0.001 |
| Smoker | 381 (54.6%) | 46 (41.8%) | 335 (57.0%) | 0.002 |
| Family history of coronary artery disease | 76 (11.4%) | 5 (4.9%) | 71 (12.5%) | 0.01 |
| Previous known CAD | 283 (40.8%) | 38 (34.5%) | 245 (42.0%) | 0.09 |
| Peripheral artery disease | 56 (8.0%) | 14 (12.7%) | 42 (7.2%) | 0.04 |
| STEMI index hospitalization features | ||||
| Total ischemic time (minutes), median (IQR) | 240 (150-440) | 330 (180-600) | 235 (150-390) | 0.001 |
| Door-to-balloon time (minutes), median (IQR) | 80 (50-120) | 90 (60-200) | 75 (50-120) | 0.004 |
| Systolic blood pressure (mmHg), mean (SD) | 122.3 (24.3) | 121.3 (26.5) | 122.5 (23.9) | 0.63 |
| Killip-Kimball class | ||||
| I | 557 (79.6%) | 56 (50.9%) | 501 (84.9%) | <0.001 |
| II | 86 (12.3%) | 29 (26.4%) | 57 (9.7%) | <0.001 |
| III | 13 (1.9%) | 7 (6.4%) | 6 (1.0%) | <0.001 |
| IV | 44 (6.3%) | 18 (16.4%) | 26 (4.4%) | <0.001 |
| Hemoglobin (g/dL), mean (SD) | 14.2 (1.8) | 13.6 (1.9) | 14.3 (1.7) | 0.001 |
| eGFR (mL/min), mean (SD) | 92.2 (35.2) | 78.7 (34.5) | 94.7 (34.7) | <0.001 |
| LAD culprit lesion | 291 (41.6%) | 59 (53.6%) | 232 (39.3%) | 0.004 |
| Peak troponin level (ng/mL), median (IQR) | 4.0 (2.3-7.3) | 6.0 (3.2-10.3) | 3.8 (2.1-6.9) | <0.001 |
| Stroke | 6 (0.9%) | 3 (2.8%) | 3 (0.5%) | 0.02 |
| LVEF at hospital discharge, mean (SD) | 45.6 (10.4) | 40.3 (12.0) | 46.6 (9.7) | <0.001 |
| LVEF <50% at hospital discharge | 412 (58.9%) | 83 (75.5%) | 339 (57.5%) | <0.001 |
| Medication at hospital discharge | ||||
| Beta-blocker | 603 (86.1%) | 99 (90.8%) | 504 (86.9%) | 0.16 |
| ACE-I/ARB | 430 (62.4%) | 70 (64.2%) | 360 (62.1%) | 0.38 |
| Statin | 678 (98.4%) | 109 (100%) | 569 (98.1%) | 0.15 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
