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The Prognostic Impact of Multiple Adverse Events on Long-Term Mortality Following Acute Myocardial Infarction
Kyung Hoon Roh1, Yong Hee Kim2, Eun Ho Choo3
1Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Background:
Adverse events after acute myocardial infarction (AMI) are individually associated with poor outcomes, but the prognostic impact of the overlap of different event types occurring sequentially within the same patient remains uncertain.
Aims:
Mortality associated with multiple events-defined as ≥ 2 different event types among spontaneous myocardial infarction (MI), ischemic stroke, and major bleeding-was compared with single events after AMI.
Methods:
We analyzed 10,719 AMI patients in the multicenter Korean AMI registry. Patients contributed person-time to mutually exclusive, time-varying states: no event; MI only; stroke only; Bleeding Academic Research Consortium (BARC) type 3 bleeding only; and multiple events (≥ 2 different types). Mortality was modeled using multivariable Cox regression with stabilized inverse-probability weighting (IPW) and piecewise intervals for early (≤ 30 days), intermediate (30 days to 1 year), and late (>1 year) risk.
Results:
Over a median 4.9 years, 2625 patients died. Multiple events occurred in 108 patients (1.0%): MI + bleeding (55%), stroke+bleeding (31%), and MI + stroke (15%). Mortality patterns were consistent across multiple-event combinations. Multiple events conferred the highest risk of death (5-year IPW-adjusted hazard ratio [HR]: 5.85, 95% confidence interval [CI]: 3.48-9.85), exceeding MI only (HR: 3.78), stroke only (HR: 2.72), or bleeding only (HR: 3.08). Mortality was most pronounced within 30 days, most markedly after multiple events (IPW-adjusted HR: 24.0, 95% CI: 12.9-44.7).
Conclusions:
Multiple adverse events after AMI confer substantially higher mortality risk than single events, with the greatest impact in the first 30 days. These findings support the need for an immediate and tailored approach and sustained surveillance to prevent further ischemic or bleeding complications.
Insights
Experiencing multiple adverse events after acute myocardial infarction (AMI) significantly increases mortality risk compared to single events. The highest risk for these multiple events, including myocardial infarction (MI), stroke, and bleeding, is observed within the first 30 days post-AMI.
Area of Science:
- Cardiology
- Clinical Outcomes Research
- Patient Safety
Background:
- Adverse events post-acute myocardial infarction (AMI) are linked to poor outcomes.
- The combined prognostic impact of sequential, different adverse events after AMI is not well understood.
Purpose of the Study:
- To compare mortality risks associated with multiple adverse events versus single events following AMI.
- To define multiple events as two or more distinct types: spontaneous myocardial infarction (MI), ischemic stroke, or major bleeding (BARC type 3).
Main Methods:
- Analysis of 10,719 patients from the Korean AMI registry.
- Utilized time-varying states (no event, single event types, multiple events) and multivariable Cox regression with stabilized inverse-probability weighting (IPW).
- Assessed mortality risk across early (≤30 days), intermediate (30 days-1 year), and late (>1 year) periods.
Main Results:
- Over 4.9 years, 2625 deaths occurred. Multiple events (1.0% of patients) included MI+bleeding (55%), stroke+bleeding (31%), and MI+stroke (15%).
- Multiple events conferred the highest 5-year mortality risk (IPW-adjusted HR: 5.85), exceeding single events (MI: 3.78, stroke: 2.72, bleeding: 3.08).
- The highest mortality impact was observed within 30 days post-AMI (IPW-adjusted HR for multiple events: 24.0).
Conclusions:
- Multiple adverse events after AMI substantially elevate mortality risk compared to single events.
- The greatest increase in mortality risk from multiple events occurs within the initial 30 days.
- Immediate, tailored interventions and sustained surveillance are crucial to prevent subsequent ischemic or bleeding events.
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