Risk and timing of recurrent ischemic events among patients with stable ischemic heart disease, non-ST-segment
Thomas Pilgrim1, Pascal Vranckx2, Marco Valgimigli1
1Department of Cardiology, Bern University Hospital, Bern, Switzerland.
Insights
Patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) face higher mortality risk post-percutaneous coronary intervention (PCI) at all times. ST-segment elevation myocardial infarction (STEMI) patients have increased mortality within 30 days post-PCI, but not thereafter, compared to stable ischemic heart disease (SIHD).
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Research
Background:
- Comparing risks of recurrent ischemic events after percutaneous coronary intervention (PCI) is crucial for patient management.
- Stable ischemic heart disease (SIHD), non-ST-segment elevation acute coronary syndrome (NSTE-ACS), and ST-segment elevation myocardial infarction (STEMI) represent distinct clinical presentations with potentially different prognoses post-PCI.
Purpose of the Study:
- To compare the risk and timing of recurrent ischemic events among patients with SIHD, NSTE-ACS, and STEMI following PCI.
Main Methods:
- An individual patient data pooled analysis was conducted using 5 randomized controlled trials.
- Included 8,859 patients undergoing PCI, categorized into SIHD (n=3,543), NSTE-ACS (n=3,364), and STEMI (n=1,952).
- Follow-up extended to 2 years to assess recurrent ischemic events and mortality.
Main Results:
- At 2 years, all-cause mortality was significantly higher in STEMI (6.4%) and NSTE-ACS (6.1%) patients compared to SIHD (4.2%) patients.
- STEMI patients showed a mortality risk confined to the first 30 days post-PCI, while NSTE-ACS patients had elevated mortality risk both within 30 days and beyond.
- The risk of myocardial infarction beyond 30 days was comparable between STEMI and SIHD, but increased in NSTE-ACS patients.
Conclusions:
- Patients with NSTE-ACS exhibit an increased risk of death at any time point after PCI.
- While STEMI patients have a higher mortality risk within the initial 30 days post-PCI, this risk becomes similar to SIHD patients thereafter.
- These findings highlight distinct temporal risk profiles for mortality and recurrent ischemia across different acute coronary syndrome presentations post-PCI.
Background:
We aimed to compare differences in risk and timing of recurrent ischemic events among patients with stable ischemic heart disease (SIHD), non-ST-segment elevation acute coronary syndrome (NSTE-ACS), and ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).
Methods:
We performed an individual data pooled analysis of 5 randomized controlled all-comer trials including a total of 8,859 patients and investigated the risk and timing of recurrent ischemic events among patients with SIHD (n = 3,543), NSTE-ACS (n = 3,364), and STEMI (n = 1,952) throughout 2 years of follow-up.
Results:
At 2 years, all-cause mortality was higher among patients with STEMI (6.4%) and NSTE-ACS (6.1%) compared with those with SIHD (4.2%) (STEMI vs SIHD: hazard ratio [HR] 1.40, 95% CI 1.09-1.78, P = .007; NSTE-ACS vs SIHD: 1.40, 95% CI 1.13-1.73, P = .002). In a landmark analysis, the risk of mortality among patients with STEMI compared with those with SIHD was confined to the first 30 days after PCI (HR 6.19, 95% CI 3.15-12.16, P < .001) but was similar between 30 days and 2 years (HR 1.00, 95% CI 0.76-1.33, P = .974) (Pinteraction < .001). Conversely, patients with NSTE-ACS had a higher risk of mortality compared with those with SIHD both within the first 30 days (HR 2.19, 95% CI 1.08-4.47, P = .031) and beyond (HR 1.34, 95% CI 1.07-1.67, P = .012) (Pinteraction < .001). A similar pattern in the differential timing of events was observed for cardiac death. Beyond 30 days, the risk of myocardial infarction was comparable in patients with STEMI and SIHD, whereas the risk in patients with NSTE-ACS was increased (HR 1.65, 95% CI 1.23-2.21, P = .001).
Conclusion:
Whereas patients with NSTE-ACS are at increased risk for death at any time after PCI, the mortality of STEMI patients is higher during the first 30 days after PCI but not thereafter compared with patients with SIHD.
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