Summary
Background
A substantial number of patients with acute myocardial infarction (AMI) have polyvascular disease (PolyVD), defined as cerebrovascular disease (CVD), peripheral arterial disease (PAD) or both.
Aim
To investigate the impact of PolyVD on baseline characteristics, management and outcomes.
Methods
The Alliance project is a multicentre, cross-sectional database of patients with myocardial infarction throughout France from 2000 to 2005. A pooled analysis of individual patient data was performed by aggregating data from five registries, representing 9783 patients hospitalized for acute coronary syndromes. Data were collected on history of PAD and CVD and correlated to baseline characteristics, management and hospital outcomes.
Results
Eight thousand nine hundred and four patients had full datasets for this analysis (13% with a history of CVD or PAD, 87% without). Patients with PolyVD were older (72 vs 65 years, p < 0.0001), had a more frequent history of AMI (26% vs 15%, p < 0.0001), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), renal insufficiency (12% vs 3%, p < 0.0001) and consistently more risk factors for atherosclerosis (hypertension, dyslipidaemia, smoking, diabetes), but less frequently a body mass index > 30 kg/m 2 (14.0% vs 20.1%, p < 0.0001) compared to patients with coronary artery disease (CAD) alone. Killip class, left-ventricular ejection fraction and GUSTO risk score were all worse among patients with PolyVD. Management of patients with PolyVD was less aggressive (with later admission and less frequent use of in-hospital angiography or evidence-based therapies at discharge). Mortality of patients with PolyVD was consistently higher than in those with CAD alone, regardless of age. Multivariable analysis, adjusting for age, showed that both PAD (odds ratio 1.36 95% confidence interval 1.03–1.79) and history of CVD (odds ratio 1.74, 95% confidence interval 1.27–2.40) were independent predictors of hospital mortality relative to patients with CAD only.
Conclusion
Patients with PolyVD represented a substantial group among AMI patients, at particularly high risk of death, yet were managed less aggressively than patients with CAD alone. This was associated with markedly higher in-hospital mortality. Further research is warranted to design and test strategies to decrease mortality in this high-risk subset.
Résumé
Introduction
Une proportion significative de patients hospitalisés pour infarctus du myocarde (IDM) présente une atteinte vasculaire extracoronarienne associée, définie par un accident vasculaire cérébral (AVC), une atteinte artérielle périphérique (AAP) ou les deux. L’impact de cette atteinte polyvasculaire sur les caractéristiques de ces patients, leur prise en charge hospitalière et leur pronostic est mal connu.
Méthodes
Le registre Alliance est une base de données multicentrique de patients admis pour un IDM en France de 2000 à 2005. Le recueil des données a été réalisé en utilisant cinq registres représentant 9783 patients hospitalisés pour syndrome coronarien aigu entre 2000 et 2005. Les antécédents d’AVC ou d’AAP ont été colligés et corrélés aux caractéristiques cliniques, à la prise en charge médicale et interventionnelle et à la mortalité hospitalière.
Résultats
L’ensemble des données a pu être recueilli chez 8904 patients. Parmi eux, 13 % avait une atteinte polyvasculaire, alors que 87 % n’avaient pas d’antécédent d’AVC et d’AAP. Les patients avec une atteinte vasculaire extracoronarienne étaient plus âgés (72 versus 65 ans, p < 0,0001), avaient plus souvent des antécédents coronariens : antecedent d’IDM (26,1 versus 14,7 %, p < 0,0001), d’angioplastie, ou de pontage aortocoronarien, et d’insuffisance rénale (11,9 % versus 2,5 %, p < 0,0001). La prévalence des facteurs de risque cardiovasculaire (hypertension, dyslipidemie, tabac, diabète) était globalement plus importante, sauf pour l’obésité (BMI > 30) (14,0 versus 20,1 %, p < 0,0001). De même, la classe Killip était plus élevée, la fraction d’éjection plus basse et le score Gusto plus sévère. Leur prise en charge était moins agressive avec un délai entre le début des symptômes et l’admission plus long, moins de coronarographie et d’angioplastie (48 % versus 62 %, p < 0,0001), et une moindre prescription des quatre traitements recommandés par les guidelines (antiagrégants plaquettaires, bêtabloquants, statines et IEC). La mortalité hospitalière était plus élevée (12 % versus 6 %, p < 0,0001) et augmentait avec l’âge. Après ajustement pour l’âge, la présence d’antécédents d’AAP (OR : 1,36, 95 % CI : 1,03–1,79) ou d’AVC (OR 1,74, 95 % CI : 1,27–2,40) était un marqueur prédictif indépendant de mortalité hospitalière (OR 1,52 [1,23–1,88], p < 0,0001).
Conclusion
L’atteinte vasculaire extracoronaire est fréquente chez les patients hospitalisés pour IDM et identifie un sous-groupe à haut risque avec des caractéristiques plus sévères, une mortalité accrue mais une prise en charge moins agressive et un traitement médical moins souvent optimal. Des études complémentaires sont nécessaires pour évaluer l’impact d’une stratégie plus intensive sur la mortalité dans ce sous-groupe à haut risque.
Background
Cardiovascular disease, due to cerebrovascular disease (CVD), peripheral arterial disease (PAD) or coronary artery disease (CAD), is the leading cause of mortality and morbidity in industrialized countries . Atherothrombosis is a common (but not exclusive) underlying cause of these three diseases. Therefore, CVD, PAD and CAD are often different locations of a similar underlying disease, share similar risk factors (albeit with a different relative weight for each of the locations) and frequently coexist . In the REduction of Atherothrombosis for Continued Health (REACH) Registry, there was major overlap between the various locations of the symptomatic location of the disease , and mortality and morbidity increased with the extent of atherosclerotic burden (i.e., number of arterial beds affected) .
Major advances have been made in the prevention, diagnosis and treatment of CAD. Randomized trials provide robust evidence that pharmacological and interventional therapies improve the outcome of patients with acute coronary syndromes (ACS) and have led to changes in clinical practice and guidelines . Observational data from the Global Registry of Acute Coronary Events (GRACE) have shown that in routine practice, improvement in the management of patients with ACS is associated with a significant rate reduction in heart failure, acute myocardial infarction (AMI) and death. In contrast, patients with non-coronary atherosclerotic vascular disease, and especially PAD, are regarded as particularly high-risk, yet are often underdiagnosed and undertreated . For example, patients with PAD, compared to those with CAD, were less likely to be treated with aspirin or lipid-lowering therapy if they were hypercholesterolaemic .
Acute myocardial infarction is the most frequent and potentially fatal event in patients with cardiovascular disease, and the impact of the association of PAD or CVD on the management and outcome of patients hospitalized for AMI has not been fully evaluated. We hypothesized that a history of PAD or CVD may affect clinical presentation, management and outcome. We therefore used data from the Alliance consortium of AMI to compare baseline characteristics, management and in-hospital outcomes of patients with AMI alone with those of patients with associated CVD or/and PAD.
Methods
Study design
The Alliance project is a multicentre, cross-sectional database of 9783 patients admitted for AMI throughout France from 2000 to 2005. The purpose of the project is to provide aggregate data and test hypotheses regarding AMI in France. It is a pooled analysis of data from five registries: FACT (2003 nationwide survey with 2517 patients) , USIC (2000 nationwide survey with 2315 patients) , RICO (2000–2005 continuous registry department of Burgondy with 4057 patients) , Paris (2000–2005 continuous registry of University Hospital Pitié-Salpétrière Paris with 652 patients) and eParis (2000–2005 continuous registry with 242 patients). All patients gave informed consent for participation in the survey and follow-up.
Definitions
Acute myocardial infarction was defined as an increase in one cardiac biochemical marker of necrosis (troponin I or T or creatine phosphokinase [CPK] MB) at least twice the upper normal limit and at least one of the following criteria: chest pain lasting for at least 20 minutes not relieved by nitrates, electrocardiographic changes on at least two contiguous leads with persisting ST elevation or depression ≥ 0.1 mV and/or pathological Q waves. Patients were classified into three categories: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) or undetermined electrocardiographic pattern (left bundle-branch block or paced rhythm).
Vascular disease
Diagnosis of PAD was made on the basis of the presence of one of the following: history of claudication, peripheral vascular surgery, vascular angioplasty or amputation or documented abdominal aortic aneurysm. The diagnosis of CVD was based on a history of transient ischaemic attack (TIA), stoke, carotid endarterectomy or carotid stent implantation. TIA was defined as a history of loss of neurological function caused by ischaemia that was abrupt in onset but with complete return of function within 24 hours. Stroke was defined as a loss of neurological function caused by an ischaemic event, with residual symptoms.
Data collection
Data regarding patient demographics, risk factors, medical history, clinical presentation, prehospital delay, in-hospital management and in-hospital mortality were collected. Polyvascular disease (PolyVD) was defined as patients with CVD, PAD or both. Items used for the pooled analysis were defined in a similar manner across registries, using simple clinical definitions.
Statistical analysis
Data are presented as number of patients (per cent) or mean ± standard deviation (SD). Differences in baseline characteristics, hospital management and mortality between patients with and without PolyVD were assessed by use of the t test or the χ 2 -test as appropriate. Final regression models were adjusted for age divided into three categories (< 60; 60–75; > 75 years) or as a continuous variable. A p value < 0.05 was considered significant.
Results
Baseline characteristics
Among the 9783 patients with AMI enrolled in the five registries between 2000 and 2005, 91% ( n = 8904) had complete datasets and constituted our study population. Clinical characteristics are summarized in Table 1 . Briefly, the mean age was 66 ± 14 years, 72% were men and the prevalence of cardiovascular risk factors was high.
| Variable | Overall ( n = 8904) | No PolyVD ( n = 7743) | PolyVD ( n = 1161) | p |
|---|---|---|---|---|
| Age (years) | 66 ± 14 | 65 ± 14 | 72 ± 12 | < 0.0001 |
| Men | 6409 (72) | 5550 (72) | 859 (74) | 0.10 |
| Cardiovascular risk factors | ||||
| Hypertension | 4455 (50) | 3691 (48) | 764 (66) | < 0.0001 |
| Diabetes | 1830 (21) | 1435 (19) | 395 (34) | < 0.0001 |
| Dyslipidaemia | 3867 (43) | 3317 (43) | 550 (47) | 0.004 |
| History of smoking (current or former) | 5277 (59) | 4543 (59) | 734 (63) | 0.003 |
| Obesity (body mass index ≥30 kg/m 2 ) | 1606 (19) | 1457 (20) | 149 (14) | < 0.0001 |
| Renal insufficiency (glomerular filtration rate ≤30 mL/min) | 239 (4) | 140 (3) | 99 (12) | < 0.0001 |
| History of coronary artery disease | ||||
| Myocardial infarction | 1441 (16) | 1138 (15) | 303 (26) | < 0.0001 |
| Percutaneous coronary intervention | 943 (11) | 765 (10) | 178 (15) | < 0.0001 |
| Coronary artery bypass graft | 384 (4) | 303 (4) | 81 (7) | < 0.0001 |
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