Clinical Investigation
Acute Ischemic Heart Disease
Effect of comorbidity on coronary reperfusion strategy and long-term mortality after acute myocardial infarction

https://doi.org/10.1016/j.ahj.2005.06.037Get rights and content

Background

Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction (STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies.

Methods

Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention (PCI) facilities. Three categories of increasing chronic comorbidity score (CS-1, n = 259; CS-2, n = 235; CS-3, n = 246) were identified from age-adjusted associations of comorbidities with 1-year survival.

Results

Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy (PCI in 91.5% of 470 cases) was adopted less frequently (P < .001) in CS-3 (41.9%) than CS-2 (69.4%) or CS-1 (78.8%). Compared with conservative therapy (n = 270), reperfusion therapy reduced 1-year mortality in the whole series not significantly (P = .816) in CS-1 but significantly in CS-2 (P = .012) and CS-3 (P = .001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location (hazard ratio [HR] = 0.63 [95% CI 0.14-2.80], HR = 0.62 [95% CI 0.31-1.25], and HR = 0.47 [95% CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21 (crude analysis) to 20 (adjusted analysis) deaths were classified as potentially avoidable.

Conclusion

Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.

Section snippets

Patient population

The design of the AMI-Florence registry has been detailed elsewhere.10 Briefly, the Florence health district (about 800 000 inhabitants) comprises 5 community hospitals and 1 teaching hospital, the latter implementing high-volume programs for primary PCI (fully operative 24 h/d, 7 d/wk). All residents in the Florence area arriving alive to the emergency department of 1 of the 6 hospitals between March 2000 and February 2001 with a suspected STEMI were prospectively screened for eligibility and

Results

Overall, 198 patients had no comorbidity, whereas 542 had at least one chronic comorbidity. Of these, 184 had a cardiac, 135 a noncardiac, and 223 at least one cardiac and one noncardiac comorbidity. The prevalence of comorbidity increased from 48% at age <55 years to 83% at age >74 years (P < .001).

The prevalence of each comorbidity and results from age-adjusted bivariate Cox analyses testing the association of comorbidities with 1-year prognosis, which were used to calculate individual

Discussion

The most rapid and complete coronary reperfusion is the desirable therapeutic goal to be achieved in acute MI.1 At least in selected subgroups in whom thrombolysis is known to be less effective or relatively contraindicated,4 primary PCI may produce better results and extends the benefit of coronary reperfusion to nearly all cases of STEMI.13 Whereas underutilization of thrombolysis in older patients with AMI may be justified, at least in part, by an age-associated increase in the

References (19)

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