Cardiovascular Events and Long-Term Risk of Sudden Death Among Stabilized Patients After Acute Coronary Syndrome:
Christopher B Fordyce1, Robert P Giugliano2, Christopher P Cannon2
1Division of Cardiology University of British Columbia Vancouver BC Canada.
Insights
Patients stabilized after acute coronary syndrome (ACS) face long-term sudden death risk, especially after subsequent cardiovascular events. Identifying these risks can improve patient care and outcomes.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- Long-term outcomes after acute coronary syndrome (ACS) are less understood for stabilized patients compared to those with low ejection fraction.
- Sudden death remains a significant concern following ACS, necessitating further investigation into its predictors and timing.
Purpose of the Study:
- To determine the long-term incidence of sudden death in patients stabilized after ACS.
- To investigate the association between subsequent cardiovascular events and the risk of sudden death in this population.
Main Methods:
- Analysis of 18,144 patients stabilized within 10 days of ACS from the IMPROVE-IT trial.
- Calculation of cumulative incidence rates and incidence rates per 100 patient-years for sudden death.
- Cox proportional hazards models used to assess the impact of postrandomization cardiovascular events (myocardial infarction, stroke, heart failure) on sudden death risk.
Main Results:
- Of 2446 total deaths, 402 (16%) were sudden, with a median time to sudden death of 2.7 years.
- The cumulative incidence of sudden death was 2.47% at 7 years.
- Subsequent cardiovascular events, particularly myocardial infarction and heart failure, significantly increased the risk of sudden death (HR 3.64 and 4.55, respectively).
Conclusions:
- Stabilized ACS patients are at ongoing risk for sudden death, extending beyond the initial post-event period.
- The occurrence of additional cardiovascular events post-ACS is a critical risk factor for future sudden death.
- These findings highlight opportunities for clinicians to refine risk assessment and improve long-term management strategies for ACS survivors.
Abstract:
Background Unlike patients with low ejection fraction after an acute coronary syndrome (ACS), little is known about the long-term incidence and influence of cardiovascular events before sudden death among stabilized patients after ACS. Methods and Results A total of 18 144 patients stabilized within 10 days after ACS in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial) were studied. Cumulative incidence rates (IRs) and IRs per 100 patient-years of sudden death were calculated. Using Cox proportional hazards, the association of ≥1 additional postrandomization cardiovascular events (myocardial infarction, stroke, and hospitalization for unstable angina or heart failure) with sudden death was examined. Early (≤1 year after ACS) and late sudden deaths (>1 year) were compared. Of 2446 total deaths, 402 (16%) were sudden. The median time to sudden death was 2.7 years, with 109 early and 293 late sudden deaths. The cumulative IR was 2.47% (95% CI, 2.23%-2.73%) at 7 years of follow-up. The risk of sudden death following a postrandomization cardiovascular event (150/402 [37%] sudden deaths; median 1.4 years) was greater (IR/100 patient-years, 1.45 [95% CI, 1.23-1.69]) than the risk with no postrandomization cardiovascular event (IR/100 patient-years, 0.27 [95% CI, 0.24-0.30]). Postrandomization myocardial infarction (hazard ratio [HR], 3.64 [95% CI, 2.85-4.66]) and heart failure (HR, 4.55 [95% CI, 3.33-6.22]) significantly increased future risk of sudden death. Conclusions Patients stabilized within 10 days of an ACS remain at long-term risk of sudden death with the greatest risk in those with an additional cardiovascular event. These results refine the long-term risk and risk effectors of sudden death, which may help clinicians identify opportunities to improve care. Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00202878.
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