jeudi 31 mars 2016

Heart Failure Risk Rises With CAD Burden Post-MI (CME/CE)

Action Points

  • Note that this observational cohort study found that extent of coronary disease at first myocardial infarction was a predictor of subsequent heart failure, independent of subsequent MI.
  • It remains unclear whether more extensive revascularization at the time of first MI would be beneficial in all patients.

A first heart attack is more likely to lead to heart failure in patients with a high burden of coronary artery disease (CAD), according to a newly published study.

Compared with post-myocardial infarction (MI) patients with no more than one occluded coronary artery, those with two obstructed arteries were 25% more likely to suffer heart failure within 6 years. That risk rose to 75% in patients with three blocked arteries, senior investigator Véronique Roger, MD, of the Mayo Clinic in Rochester, Minn., and colleagues reported online in JAMA Cardiology.

"This study provides important information on the role of the extent of coronary disease at the time of the first MI on the future development of heart failure. The more extensive coronary disease is, the higher the risk of heart failure, regardless of whether or not another infarction occurs," Roger said in an email to MedPage Today.

"These findings underscore the need to examine if complete revascularization strategies would help prevent heart failure after MI," Roger said.

The population-based cohort study included 1,922 patients with incident MI diagnosed from 1990 through 2010 who had no history of heart failure. More than half (65%) were men, and their mean age was 64.

Roger and colleagues followed these patients through early 2013 (mean follow-up 6.7 years). The investigators determined the extent of angiographic CAD at baseline and categorized the disease burden according to the number of major epicardial coronary arteries with 50% or more lumen diameter obstruction.

A total of 588 patients (30.6%) developed heart failure, ascertained by the Framingham criteria, during the follow-up.

With death and recurrent MI modeled as competing risks, the cumulative incidence rates of post-MI heart failure among the patients, categorized according to the number of obstructed arteries, were as follows (P<0.001 for trend):

  • 0-1 obstructed artery: 10.7% at 30 days and 14.7% at 5 years
  • 2 obstructed arteries: 14.6% at 30 days and 20.6% at 5 years
  • 3 obstructed arteries: 23% at 30 days and 29.8% at 5 years

Compared with patients with zero or one blocked artery, those with two blocked arteries had a significantly increased risk for heart failure (hazard ratio 1.25; 95% confidence interval 0.99-1.59; P<0.001). In patients with three blocked arteries, the risk was much higher (HR 1.75; 95% CI 1.40-2.20; P<0.001).

This increased risk occurred independently of recurrent MI, and it did not change with heart failure subtypes (reduced or preserved ejection fraction), Roger and colleagues reported.

"During the past 2 decades, major changes in the epidemiology of MI have occurred. Progress in its acute treatment improved short-term survival, but heart failure remains frequent after MI and leads to excess mortality. Hence, the acute treatment of MI aimed at restoring vessel patency is not sufficient to prevent heart failure, underscoring the importance of understanding the contemporary mechanisms leading to its development," Roger and colleagues said.

In particular, "The mechanisms through which concomitant atherosclerosis in coronary vessels other than the culprit artery adversely affect heart failure risk post-MI need further study," they suggested.

A chief limitation of the study was that the cohort was mostly white, "which may limit the generalizability to groups not adequately represented," the investigators noted.

The study was funded by the National Institutes of Health.

No researchers reported relevant financial relationships with industry.

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Heart Failure Risk Rises With CAD Burden Post-MI (CME/CE)

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