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Polyvascular disease and long-term cardiovascular outcomes in older patients with non-ST-segment-elevation myocardial
Sumeet Subherwal1, Deepak L Bhatt, Shuang Li
1Duke University Medical Center, Durham, NC, USA.
Insights
Older patients with polyvascular disease (peripheral arterial disease and cerebrovascular disease) face a significantly higher long-term risk of death or recurrent cardiovascular events after myocardial infarction.
Area of Science:
- Cardiology
- Vascular Medicine
- Geriatrics
Background:
- Polyvascular disease, encompassing peripheral arterial disease (PAD) and cerebrovascular disease (CVD), is prevalent in older acute myocardial infarction (AMI) patients.
- The long-term impact of PAD and CVD on cardiovascular outcomes post-AMI is not well-established.
Purpose of the Study:
- To investigate the association between polyvascular disease and long-term mortality and major adverse cardiovascular events in older patients with non-ST-segment-elevation myocardial infarction (NSTEMI).
Main Methods:
- Analysis of 34,205 older NSTEMI patients from the CRUSADE registry, linked to Medicare data.
- Patients were categorized into four groups: coronary artery disease (CAD) alone, CAD+PAD, CAD+CVD, and CAD+PAD+CVD.
- Cox proportional hazards modeling was used to assess long-term mortality and composite ischemic events.
Main Results:
- Patients with polyvascular disease had higher comorbidity burdens, lower revascularization rates, and less adherence to discharge interventions compared to the CAD alone group.
- Three-year mortality rates increased with the number of affected arterial beds: 33% (CAD alone), 49% (CAD+PAD), 52% (CAD+CVD), and 59% (CAD+PAD+CVD).
- The highest risk for long-term mortality (adjusted HR, 1.49) and composite ischemic events was observed in patients with involvement of all three arterial beds (CAD+PAD+CVD).
Conclusions:
- Polyvascular disease significantly elevates the long-term risk of death and recurrent cardiovascular events in older NSTEMI patients.
- This vulnerable population requires enhanced secondary prevention strategies and novel therapeutic approaches to mitigate adverse outcomes.
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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