Common comorbidities and survival for patients with acute myocardial infarction

Takeaway

• In patients with acute myocardial infarction (AMI), co-existence of diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD) or asthma, chronic heart failure (CHF) and cerebrovascular disease is common and inversely associated with receipt of optimal guideline-recommended care.
• Overall, guideline-indicated care is associated with improvements in mortality; however, no improvement in survival is seen in patients with concomitant CHF or cerebrovascular disease.

• Findings suggest there may be a need for novel treatments to improve outcomes for patients with AMI with pre-existing CHF or cerebrovascular disease.

Study design

• This study included 693,388 patients with AMI (274,220 [39.6%] ST-elevated MI [STEMI] and 419,168 [39.6%] non-STEMI) without comorbidities (n=280,579 [40.5%]) and with ≥1 comorbidity (n=412,809 [59.5%]) using data from the MINAP registry.
• Funding: Wellcome Trust.

• The most prevalent comorbidity was hypertension (302,388 [43.6%]), followed by DM (122,228 [17.6%]), COPD or asthma (89,221 [12.9%]), cerebrovascular disease (51,883 [7.5%]), CHF (33,813 [4.9%]), chronic renal failure (31,029 [4.5%]) and peripheral vascular disease (27,627 [4.0%]).
• The presence of each comorbidity, with the exception of hypertension, renal failure, and peripheral vascular disease, was associated with a reduced chance of receiving optimal care.
• The effect was most pronounced in those with CHF (OR, 0.63; 95% CI, 0.60-0.65), followed by cerebrovascular disease (OR, 0.86; 95% CI, 0.84-0.89), DM (OR, 0.89; 95% CI, 0.88-0.91) and COPD (OR, 0.92; 95% CI, 0.89-0.94).
• Over the 8.5-year follow-up period, the receipt of optimal AMI care was associated with greatest survival benefit for patients without comorbidities (adjusted HR [aHR], 0.53; 95% CI, 0.51-0.56), followed by those with:
  • hypertension (aHR, 0.60; 95% CI, 0.58-0.62);
  • DM (aHR, 0.83; 95% CI, 0.80-0.87);
  • peripheral vascular disease (aHR, 0.85; 95% CI, 0.79-0.91);
  • chronic renal failure (aHR, 0.89; 95% CI, 0.84-0.94); and
  • COPD (aHR, 0.90; 95% CI, 0.87-0.94).
• The receipt of optimal AMI treatment was not associated with a significant change in survival in patients with:
  • CHF (HR, 1.02; 95% CI, 0.96-1.09);
  • cerebrovascular disease (HR, 0.97; 95% CI, 0.92-1.02); and
  • in those with ≥2 comorbidities (HR, 1.00; 95% CI, 0.97-1.03).

• While case ascertainment in MINAP is high, not all cases of non-STEMI in England and Wales are entered in the registry.