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. 2012 Jul 1;5(4):541-9.
doi: 10.1161/CIRCOUTCOMES.111.964379. Epub 2012 Jun 19.

Polyvascular disease and long-term cardiovascular outcomes in older patients with non-ST-segment-elevation myocardial infarction

Sumeet Subherwal  1 , Deepak L Bhatt, Shuang Li, Tracy Y Wang, Laine Thomas, Karen P Alexander, Manesh R Patel, E Magnus Ohman, W Brian Gibler, Eric D Peterson, Matthew T Roe
Affiliations

Polyvascular disease and long-term cardiovascular outcomes in older patients with non-ST-segment-elevation myocardial infarction

Sumeet Subherwal et al. Circ Cardiovasc Qual Outcomes. .

Abstract

Background: The impact of polyvascular disease (peripheral arterial disease [PAD] and cerebrovascular disease [CVD]) on long-term cardiovascular outcomes among older patients with acute myocardial infarction has not been well studied.

Methods and results: Patients with non-ST-segment-elevation myocardial infarction aged ≥65 years from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) registry who survived to hospital discharge were linked to longitudinal data from the Centers for Medicare & Medicaid Services (n=34 205). All patients were presumed to have coronary artery disease (CAD) and were classified into the following 4 groups: 10.7% with prior CVD (CAD+CVD group); 11.5% with prior PAD (CAD+PAD); 3.1% with prior PAD and CVD (CAD+PAD+CVD); and 74.7% with no polyvascular disease (CAD alone). Cox proportional hazards modeling was used to examine the hazard of long-term mortality and composite of death or readmission for myocardial infarction or stroke (median follow-up, 35 months; interquartile range, 17-49 months). Compared with the CAD alone group, patients with polyvascular disease had greater comorbidities, were less likely to undergo revascularization, and received less often recommended discharge interventions. Three-year mortality rates increased with number of arterial bed involvement as follows: 33% for CAD alone, 49% for CAD+PAD, 52% for CAD+CVD, and 59% for CAD+PAD+CVD. Relative to the CAD alone group, patients with all 3 arterial beds involved had the highest risk of long-term mortality (adjusted hazard ratio [95% CI], 1.49 [1.38-1.61]; CAD+CVD, 1.38 [1.31-1.44]; CAD+PAD, 1.29 [1.23-1.35]). Similarly, the risk of long-term composite ischemic events was highest among patients in the CAD+PAD+CVD group.

Conclusions: Among older patients with non-ST-segment-elevation myocardial infarction, those with polyvascular disease have substantially higher long-term risk for recurrent events or death. Future studies targeting greater adherence to secondary prevention strategies and novel therapies are needed to help to reduce long-term cardiovascular events in this vulnerable population.

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Conflict of interest statement

Conflict-of-interest Disclosures

Sumeet Subherwal: None.

Deepak L. Bhatt: Research grants from AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, sanofi-aventis, and The Medicines Company.

Shuang Li: None.

Tracy Y. Wang: Research grants to DCRI from BMS/sanofi Partnership, Schering-Plough (now Merck), The Medicines Company, Canyon Pharmaceuticals, Heartscape, Eli Lilly/Daiichi Sankyo Partnership; consulting/honoraria from Heartscape, Medco, and American College of Cardiology Foundation. All conflicts of interest are listed at www.dcri.org.

Laine Thomas: None.

Karen P. Alexander: None.

Manesh R. Patel: Research support from MAQUET Cardiovascular LLC (formerly Boston Scientific Cardiac & Vascular), Johnson & Johnson, NHLBI, and AHRQ; consulting for Genzyme. All conflicts of interest are listed at www.dcri.org.

E. Magnus Ohman: Research support from Daiichi Sankyo, Datascope, Eli Lilly & Company; consulting for AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, Liposcience, Merck, Pozen, Inc., sanofi-aventis, The Medicines Company, WebMD. All conflicts of interest are listed at www.dcri.org.

W. Brian Gibler: None.

Eric D. Peterson: Research support from Bristol-Myers Squibb, Eli Lilly & Company, Johnson & Johnson, Merck & Co., sanofi-aventis, American Heart Association, American College of Cardiology, Society of Thoracic Surgeons; consulting for Boehringer Ingelheim. All conflicts of interest are listed at www.dcri.org.

Matthew T. Roe: Research funding from Eli Lilly, Roche, Bristol-Myers Squibb, American College of Cardiology, American Heart Association; consulting or honoraria from: KAI Pharmaceuticals, Bristol-Myers Squibb, sanofi-aventis, Merck, Orexigen, Helsinn Pharmaceuticals, AstraZeneca, Regeneron. All conflicts of interest are listed at www.dcri.org.

Figures

Figure 1
Figure 1
Long-term outcomes after NSTEMI by previous vascular bed involvement. 1a: Mortality; 1b: Readmission rates for ischemic stroke; 1c: Readmission for MI; 1d: Composite of death, readmission for MI, or readmission for stroke.
Figure 1
Figure 1
Long-term outcomes after NSTEMI by previous vascular bed involvement. 1a: Mortality; 1b: Readmission rates for ischemic stroke; 1c: Readmission for MI; 1d: Composite of death, readmission for MI, or readmission for stroke.
Figure 1
Figure 1
Long-term outcomes after NSTEMI by previous vascular bed involvement. 1a: Mortality; 1b: Readmission rates for ischemic stroke; 1c: Readmission for MI; 1d: Composite of death, readmission for MI, or readmission for stroke.
Figure 1
Figure 1
Long-term outcomes after NSTEMI by previous vascular bed involvement. 1a: Mortality; 1b: Readmission rates for ischemic stroke; 1c: Readmission for MI; 1d: Composite of death, readmission for MI, or readmission for stroke.
Figure 2
Figure 2
Kaplan-Meier estimates of mortality after NSTEMI by previous vascular bed involvement.
Figure 3
Figure 3
Kaplan-Meier estimates of death, MI readmission, or stroke readmission by degree of polyvascular disease.
See this image and copyright information in PMC

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