The Hypertension Paradox: Survival Benefit After ST-Elevation Myocardial Infarction in Patients With History of
Fabian Hoffmann1,2, Patricia Fassbender3, Wilhelm Zander1
1Department of Internal Medicine III, University of Cologne, Cologne, Germany.
Insights
Patients with a history of hypertension had better survival after ST-elevation myocardial infarction (STEMI). This is linked to higher adherence to guideline-recommended therapies, including RAS-inhibitors, beta-blockers, and statins.
Area of Science:
- Cardiology
- Clinical Medicine
- Pharmacotherapy
Background:
- Mortality following ST-elevation myocardial infarction (STEMI) is significantly influenced by the quality of medical treatment post-event.
- Guideline-recommended therapies play a crucial role in improving outcomes for STEMI patients.
Purpose of the Study:
- To evaluate the impact of guideline-recommended therapy prescription on survival in STEMI patients.
- To compare outcomes between STEMI patients with and without a history of arterial hypertension.
Main Methods:
- A cohort of 1,025 STEMI patients from the Cologne Infarction Model registry were analyzed.
- Patients were stratified based on their history of hypertension, and prescription rates/dosing of RAS-inhibitors, beta-blockers, and statins were recorded.
- All-cause death was the primary outcome, with a mean follow-up of 2.5 years.
Main Results:
- Patients with a history of hypertension (76%) exhibited lower all-cause mortality (HR: 0.37 at 1 year) compared to those without.
- After adjusting for multiple factors, 1-year mortality remained significantly lower in hypertensive patients (HR: 0.24).
- Higher prescription rates and dosages of guideline-recommended drugs were observed in hypertensive patients at discharge, correlating with reduced mortality.
Conclusions:
- STEMI patients with a history of hypertension demonstrate increased adherence to guideline-recommended drug therapies, potentially contributing to improved survival.
- The better tolerance of beta-blockers and RAS-inhibitors in hypertensive patients, rather than hypertension itself, may explain these observed differences in prescription and dosing.
Background:
Mortality after ST-elevation myocardial infarction (STEMI) is dependent from best-medical treatment after initial event.
Objectives:
Determining the impact of prescription of guideline-recommended therapy after STEMI in two cohorts, patients with and without history of arterial hypertension, on survival.
Methods:
1,025 patients of the Cologne Infarction Model registry with invasively adjudicated STEMI were dichotomized according to their history of arterial hypertension. We recorded prescription rates and dosing of RAS-inhibitors, β-blockers and statins in all patients. The primary outcome was all-cause death. Mean follow-up was 2.5 years.
Results:
Mean age was 64 ± 13 years, 246 (25%) were women. 749 (76%) patients had a history of hypertension. All-cause mortality was 24.2%, 30-day and 1-year mortality was 11.3% and 16.6%, respectively. History of hypertension correlated with lower mortality (hazard ratio [HR], @30 days: 0.41 [0.27-0.62], @1 year: 0.37 [0.26-0.53]). After adjusting for age, sex, Killip-class, diabetes mellitus, body-mass index, kidney function and statin prescription at discharge 1-year mortality HR was 0.24 (0.12-0.48). At discharge, prescription rates for RAS-inhibitors, β-blockers and statins, as well as individual dosing and long-term persistence of RAS-inhibitors were higher in patients with history of hypertension. On the same lines, prescription rates for RAS-inhibitors, β-blockers and statins at discharge correlated significantly with lower mortality regardless of history of hypertension.
Conclusion:
Patients with history of hypertension show higher penetration of guideline recommended drug therapy after STEMI, which may contribute to better survival. Better tolerance of β-blockers and RAS-inhibitors in patients with history of hypertension, not hypertension itself, likely explains these differences in prescription and dosing.
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