Effect of comorbidity on coronary reperfusion strategy and long-term mortality after acute myocardial infarction
Daniela Balzi1, Alessandro Barchielli, Eva Buiatti
1Epidemiology Unit, Local Health Unit 10, Florence, Italy. daniela.balzi@asf.toscana.it
Insights
Patients with chronic comorbidity and ST-segment elevation myocardial infarction (STEMI) have higher mortality partly due to underuse of reperfusion therapy. A more aggressive treatment approach could reduce deaths in these high-risk patients.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- Chronic comorbidity significantly impacts prognosis in ST-segment elevation myocardial infarction (STEMI).
- The influence of comorbidity on STEMI outcomes may be linked to therapeutic strategy variations.
- Understanding this relationship is crucial for optimizing patient care.
Purpose of the Study:
- To investigate the independent effect of chronic comorbidity on STEMI mortality.
- To determine if differences in therapeutic strategies mediate the impact of comorbidity on outcomes.
- To evaluate the potential for improved outcomes with more aggressive treatment.
Main Methods:
- A population-based registry of 740 STEMI patients hospitalized within 12 hours of symptom onset was analyzed.
- Patients were categorized into three chronic comorbidity score (CS) groups (CS-1, CS-2, CS-3) based on 1-year survival associations.
- Therapeutic strategies, including percutaneous coronary intervention (PCI), were compared across comorbidity groups.
Main Results:
- Higher comorbidity scores (CS) were associated with reduced rates of direct admission or transfer to PCI-capable hospitals.
- Coronary reperfusion therapy (primarily PCI) was utilized less frequently in higher CS groups (CS-3: 41.9%) compared to lower CS groups (CS-1: 78.8%).
- Reperfusion therapy significantly reduced 1-year mortality in CS-2 (P=.012) and CS-3 (P=.001) patients, but not in CS-1 (P=.816).
Conclusions:
- Increased STEMI mortality in patients with chronic comorbidity is partly attributable to the underutilization of coronary reperfusion therapy.
- A more aggressive therapeutic strategy, particularly increased use of reperfusion therapy, may reduce mortality in these patients.
- Potentially avoidable deaths were identified, highlighting the need for optimized treatment protocols.
Background:
Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction (STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies.
Methods:
Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention (PCI) facilities. Three categories of increasing chronic comorbidity score (CS-1, n = 259; CS-2, n = 235; CS-3, n = 246) were identified from age-adjusted associations of comorbidities with 1-year survival.
Results:
Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy (PCI in 91.5% of 470 cases) was adopted less frequently (P < .001) in CS-3 (41.9%) than CS-2 (69.4%) or CS-1 (78.8%). Compared with conservative therapy (n = 270), reperfusion therapy reduced 1-year mortality in the whole series not significantly (P = .816) in CS-1 but significantly in CS-2 (P = .012) and CS-3 (P = .001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location (hazard ratio [HR] = 0.63 [95% CI 0.14-2.80], HR = 0.62 [95% CI 0.31-1.25], and HR = 0.47 [95% CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21 (crude analysis) to 20 (adjusted analysis) deaths were classified as potentially avoidable.
Conclusion:
Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.
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