Spontaneous MI After Non-ST-Segment Elevation Acute Coronary Syndrome Managed Without Revascularization: The TRILOGY
Renato D Lopes1, Sergio Leonardi2, Benjamin Neely3
1Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
Insights
Spontaneous myocardial infarction (MI) is common in acute coronary syndrome (ACS) patients managed medically. Baseline factors can predict future spontaneous MI risk in these individuals.
Area of Science:
- Cardiology
- Clinical Research
- Outcomes Research
Background:
- Patients with acute coronary syndrome (ACS) managed medically without revascularization face a high risk of spontaneous myocardial infarction (MI).
- The frequency and predictors of spontaneous MI in this population were previously unknown.
Purpose of the Study:
- To characterize spontaneous MI events in a randomized ACS population over 30 months.
- To develop a prediction model for spontaneous MI to assess risk in ACS patients.
Main Methods:
- Analysis of data from the TRILOGY ACS trial (N=9,294) for patients with non-ST-segment elevation myocardial infarction (NSTEMI)/unstable angina (UA) managed medically.
- Development and validation of a multivariable Cox proportional hazards model to identify predictors of spontaneous MI.
- Creation of a risk calculator based on the validated model.
Main Results:
- Spontaneous MI occurred in 695 patients (10.7% at 30 months) and comprised 94% of all MI events.
- Key predictors identified: older age, NSTEMI vs. UA index event, diabetes, no prior angiography, and higher creatinine.
- The prediction model demonstrated good predictive capability (c-index=0.732) and calibration, particularly for low-to-moderate risk patients.
Conclusions:
- Spontaneous MI is a frequent event in medically managed UA/NSTEMI patients.
- Baseline characteristics effectively predict the risk of subsequent spontaneous MI.
- Findings aid in optimizing risk stratification and treatment for this patient group.
Background:
Patients with acute coronary syndrome (ACS), especially those receiving medical management without revascularization, are at high risk for spontaneous myocardial infarction (MI), but its frequency and predictors are unknown.
Objectives:
This study sought to characterize spontaneous MI events in a randomized population during 30 months of follow-up and develop a prediction model for spontaneous MI to assign risk of spontaneous MI events in ACS populations.
Methods:
We analyzed data from the randomized TRILOGY ACS (TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medically manage Acute Coronary Syndromes) trial of aspirin plus prasugrel or clopidogrel following ACS. The trial included 9,326 patients with non-ST-segment elevation myocardial infarction (NSTEMI)/unstable angina (UA) who were managed medically without planned revascularization. Our study population included 9,294 patients. A multivariable Cox proportional hazards model was developed to determine predictors of time to first spontaneous MI event through 30 months. After model validation, we developed a calculator for model implementation.
Results:
Among 9,294 patients, 695 spontaneous MI events occurred over a median of 17 months, representing 94% of adjudicated MI events (n = 737). The Kaplan-Meier event rate of spontaneous MI through 30 months was 10.7%. The strongest predictors of spontaneous MI were older age, NSTEMI versus UA as index event, diabetes mellitus, no pre-randomization angiography, and higher baseline creatinine values. The model exhibited good predictive capabilities (c-index = 0.732) and had good calibration, especially for patients with low-to-moderate risk of spontaneous MI.
Conclusions:
Spontaneous MI following a medically managed UA/NSTEMI event is common. Baseline characteristics can be used to predict subsequent risk of spontaneous MI in this population. These findings provide insight into the long-term natural history of medically managed UA/NSTEMI patients and could be used to optimize risk stratification and treatment of these patients. (A Comparison of Prasugrel and Clopidogrel in Acute Coronary Syndrome Subjects [TRILOGY ACS]; NCT00699998).
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