Mortality, Revascularization, and Cardioprotective Pharmacotherapy After Acute Coronary Syndrome in Patients With Severe Mental Illness: A Systematic Review and Meta-analysis

Abstract

Background and hypothesis: People with severe mental illness (SMI) may experience excess mortality and inequitable treatment following acute coronary syndrome (ACS). However, cardioprotective pharmacotherapy and SMI diagnoses other than schizophrenia are rarely examined in previous reviews. We hypothesized that SMI including bipolar disorder (BD) is associated with increased post-ACS mortality, decreased revascularization, and cardioprotective medication receipt relative to those without SMI.

Study design: We performed a meta-analysis to quantitatively synthesize estimates of post-ACS mortality, major adverse cardiac events (MACEs), and receipt of invasive coronary procedures and cardioprotective medications in patients with SMI, comprising schizophrenia, BD, and other nonaffective psychoses, relative to non-SMI counterparts. Subgroup analyses stratified by SMI subtypes (schizophrenia, BD), incident ACS status, and post-ACS time frame for outcome evaluation were conducted.

Study results: Twenty-two studies were included (n = 12 235 501, including 503 686 SMI patients). SMI was associated with increased overall (relative risk [RR] = 1.40 [95% confidence interval = 1.21-1.62]), 1-year (1.68 [1.42-1.98]), and 30-day (1.26 [1.05-1.51]) post-ACS mortality, lower receipt of revascularization (odds ratio = 0.57 [0.49-0.67]), and cardioprotective medications (RR = 0.89 [0.85-0.94]), but comparable rates of any/specific MACEs relative to non-SMI patients. Incident ACS status conferred further increase in post-ACS mortality. Schizophrenia was associated with heightened mortality irrespective of incident ACS status, while BD was linked to significantly elevated mortality only in incident ACS cohort. Both schizophrenia and BD patients had lower revascularization rates. Post-ACS mortality risk remained significantly increased with mild attenuation after adjusting for revascularization.

Conclusions: SMI is associated with increased post-ACS mortality and undertreatment. Effective multipronged interventions are urgently needed to reduce these physical health disparities.

Keywords: bipolar disorder/cardiovascular disease; coronary procedures; major adverse cardiac events; myocardial infarction; schizophrenia.

Fig. 1.

PRISMA flow chart for study selection.

Fig. 2.

Risk of mortality in ACS patients with vs without severe mental illness. Note: ACS, acute coronary syndrome; BD, bipolar disorder; CI, confidence interval; NAPD, nonaffective psychotic disorders; ONAP, other nonaffective psychoses; RE, random effect; RR, relative risk; SCZ, schizophrenia; SMI, severe mental illness. ^aNAPD comprised schizophrenia (SCZ) and ONAP, whereas ONAP included acute and transient psychotic disorders, delusional disorder, and other/unspecified nonorganic psychosis. ^bPsychiatric diagnoses (BD, SCZ) were ascertained during index admission for ACS. ^cPsychiatric diagnoses (BD, SCZ) were ascertained in outpatient settings within 12 months before index admission for ACS.

Fig. 3.

Risk of MACEs in ACS patients with vs without severe mental illness. Note: ACS, acute coronary syndrome; BD, bipolar disorder; CI, confidence interval; MACE, major adverse cardiac events; NAPD, nonaffective psychotic disorders; ONAP, other nonaffective psychoses; RE, random effect; RR, risk ratios; SCZ, schizophrenia; SMI, severe mental illness. ^aONAP included acute and transient psychotic disorders, delusional disorder, and other/unspecified nonorganic psychosis.

Fig. 4.

Receipt of cardiac procedures in ACS patients with vs without severe mental illness. Note: ACS, acute coronary syndrome; BD, bipolar disorder; CABG, coronary artery bypass grafting; CI, confidence interval; NAPD, nonaffective psychotic disorders; ONAP, other nonaffective psychoses; OR, odds ratio; PCI, percutaneous coronary intervention; RE, random effect; SCZ, schizophrenia; SMI, severe mental illness. ^aNAPD comprised schizophrenia and ONAP, whereas ONAP included acute and transient psychotic disorder, delusional disorder, and other/unspecified nonorganic psychosis.

Fig. 5.

Prescription of cardioprotective medications in ACS patients with vs without severe mental illness. Note: ACEI, angiotensin-converting enzyme inhibitors; ACS, acute coronary syndrome; ARBs, angiotensin receptor blockers; CI, confidence interval; NAPD, nonaffective psychotic disorders; RE, random effect; RR, relative risk; SCZ, schizophrenia; SMI, severe mental illness. ^aNAPD comprised schizophrenia and ONAP, whereas ONAP included acute and transient psychotic disorders, delusional disorder, and other/unspecified nonorganic psychosis.