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Published on: February 26, 2013
Stroke Risk in Patients With Reduced Ejection Fraction After Myocardial Infarction Without Atrial Fibrillation
João Pedro Ferreira1, Nicolas Girerd2, John Gregson3
1National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France; Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal.
Insights
Stroke risk after myocardial infarction (MI) can occur without atrial fibrillation (AF). A new risk score identifies patients with MI and heart failure (HF) at high risk for stroke, aiding early intervention.
Area of Science:
- Cardiology
- Neurology
- Clinical Risk Prediction
Background:
- Stroke is a known complication following myocardial infarction (MI).
- Atrial fibrillation (AF) is a common risk factor, but stroke can occur in its absence.
- Patients with MI and heart failure (HF) or systolic dysfunction are particularly vulnerable.
Purpose of the Study:
- To identify risk factors for stroke in MI patients without AF.
- To develop and validate a stroke risk score for this population.
- To aid in the early identification of high-risk individuals.
Main Methods:
- Pooled data from four major clinical trials (CAPRICORN, OPTIMAAL, VALIANT, EPHESUS).
- Analysis included 22,904 patients without AF or oral anticoagulation.
- Stroke was the primary outcome, with death as a competing risk.
Main Results:
- 660 patients (2.9%) experienced stroke during follow-up.
- Key risk factors identified: older age, higher Killip class, reduced eGFR, hypertension history, prior stroke.
- The developed risk score demonstrated good calibration and moderate-to-good discrimination (C-index = 0.67).
Conclusions:
- A simple, validated risk score for stroke in MI patients without AF has been developed.
- The score incorporates readily accessible clinical factors.
- This tool can help identify high-risk patients with MI and HF for targeted management.
Background:
Stroke can occur after myocardial infarction (MI) in the absence of atrial fibrillation (AF).
Objectives:
This study sought to identify risk factors (excluding AF) for the occurrence of stroke and to develop a calibrated and validated stroke risk score in patients with MI and heart failure (HF) and/or systolic dysfunction.
Methods:
The datasets included in this pooling initiative were derived from 4 trials: CAPRICORN (Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction), OPTIMAAL (Optimal Trial in Myocardial Infarction With Angiotensin II Antagonist Losartan), VALIANT (Valsartan in Acute Myocardial Infarction Trial), and EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study); EPHESUS was used for external validation. A total of 22,904 patients without AF or oral anticoagulation were included in this analysis. The primary outcome was stroke, and death was treated as a "competing risk."
Results:
During a median follow-up of 1.9 years (interquartile range: 1.3 to 2.7 years), 660 (2.9%) patients had a stroke. These patients were older, more often female, smokers, and hypertensive; they had a higher Killip class; a lower estimated glomerular filtration rate; and a higher proportion of MI, HF, diabetes, and stroke histories. The final stroke risk model retained older age, Killip class 3 or 4, estimated glomerular filtration rate ≤45 ml/min/1.73 m2, hypertension history, and previous stroke. The models were well calibrated and showed moderate to good discrimination (C-index = 0.67). The observed 3-year event rates increased steeply for each sextile of the stroke risk score (1.8%, 2.9%, 4.1%, 5.6%, 8.3%, and 10.9%, respectively) and were in agreement with the expected event rates.
Conclusions:
Readily accessible risk factors associated with the occurrence of stroke were identified and incorporated in an easy-to-use risk score. This score may help in the identification of patients with MI and HF and a high risk for stroke despite their not presenting with AF.
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