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Comparative Study
. 2018 Mar 20;137(12):1236-1245.
doi: 10.1161/CIRCULATIONAHA.117.031806. Epub 2017 Nov 17.

Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury

Andrew R Chapman  1 , Anoop S V Shah  2 , Kuan Ken Lee  2 , Atul Anand  2 , Oliver Francis  2 , Philip Adamson  2 , David A McAllister  3 , Fiona E Strachan  2 , David E Newby  2 , Nicholas L Mills  2
Affiliations
Comparative Study

Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury

Andrew R Chapman et al. Circulation. .

Abstract

Background: Type 2 myocardial infarction and myocardial injury are common in clinical practice, but long-term consequences are uncertain. We aimed to define long-term outcomes and explore risk stratification in patients with type 2 myocardial infarction and myocardial injury.

Methods: We identified consecutive patients (n=2122) with elevated cardiac troponin I concentrations (≥0.05 µg/L) at a tertiary cardiac center. All diagnoses were adjudicated as per the universal definition of myocardial infarction. The primary outcome was all-cause death. Secondary outcomes included major adverse cardiovascular events (eg, nonfatal myocardial infarction or cardiovascular death) and noncardiovascular death. To explore competing risks, cause-specific hazard ratios were obtained using Cox regression models.

Results: The adjudicated index diagnosis was type 1 or 2 myocardial infarction or myocardial injury in 1171 (55.2%), 429 (20.2%), and 522 (24.6%) patients, respectively. At 5 years, all-cause death rates were higher in those with type 2 myocardial infarction (62.5%) or myocardial injury (72.4%) compared with type 1 myocardial infarction (36.7%). The majority of excess deaths in those with type 2 myocardial infarction or myocardial injury were because of noncardiovascular causes (hazard ratio, 2.32; 95% confidence interval, 1.92-2.81 versus type 1 myocardial infarction). Despite this finding, the observed crude major adverse cardiovascular event rates were similar between groups (30.6% versus 32.6%), with differences apparent after adjustment for covariates (hazard ratio, 0.82; 95% confidence interval, 0.69-0.96). Coronary heart disease was an independent predictor of major adverse cardiovascular events in those with type 2 myocardial infarction or myocardial injury (hazard ratio, 1.71; 95% confidence interval, 1.31-2.24).

Conclusions: Despite an excess in noncardiovascular death, patients with type 2 myocardial infarction or myocardial injury have a similar crude rate of major adverse cardiovascular events as those with type 1 myocardial infarction. Identifying underlying coronary heart disease in this vulnerable population may help target therapies that could modify future risk.

Keywords: myocardial injury; troponin; type 2 myocardial infarction.

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Figures

Figure 1.
Figure 1.
Kaplan–Meier curves illustrating risk of death from any cause at 5 years stratified by index diagnosis, with table of number at risk. Pairwise comparison of groups obtained using the log-rank test. MI indicates myocardial infarction.
Figure 2.
Figure 2.
Cumulative incidence curves illustrating risk of major adverse cardiovascular events (type 1 myocardial infarction [MI] or cardiovascular death) and competing risk of noncardiovascular death at 5 years stratified by index diagnosis.
Figure 3.
Figure 3.
Cumulative incidence curves illustrating risk of major adverse cardiovascular events (type 1 myocardial infarction or cardiovascular death) and competing risk of noncardiovascular death in those who survive to 30 days in patients with type 1 myocardial infarction and in those with type 2 myocardial infarction or myocardial injury stratified by known CAD. CAD indicates coronary artery disease; and MI, myocardial infarction.
See this image and copyright information in PMC

Comment in

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