Cardio-renal-metabolic multimorbidity and outcomes in acute ST elevation myocardial infarction

Background Cardiovascular-renal-metabolic (CRM) multimorbidity is frequent in patients with acute ST elevation myocardial infarction (STEMI), but whether in-hospital outcomes vary in relation to CKM status and complexity remains unclear. Purpose to assess the association between CRM multimorbidity and the occurrence in-hospital acute heart failure (HF) and all-cause mortality in patients with STEMI. Methods the study included patients prospectively admitted for the first STEMI and treated with primary percutaneous coronary intervention (pPCI) in a tertiary centre. The cohort was divided by the CRM status (i.e. number of CRM conditions - 0, 1, or 2) in addition to STEMI. CRM conditions included: chronic kidney disease (CKD) - known history of CKD or estimated glomerular filtration rate at admission <60 mL/min/1.73 m2, and type 2 diabetes mellitus (T2DM) - previous diagnosis of T2DM and/or treatment with glucose-lowering medication(s). Patients with a history of myocardial infarction, prior myocardial revascularisation, HF, or cardiogenic shock were excluded. The associations between CRM subgroups (0 reference) and clinical outcomes were assessed using logistic regression analysis and a Cox proportional hazard model, adjusted for age, sex, left ventricular ejection fraction (LVEF), peak NT-pro-B type natriuretic peptide (NT-proBNP) level and STEMI myocardial area. The outcomes included in-hospital development of HF (Killip class ≥2) and in-hospital all-cause death. Results Of 542 pPCI-treated STEMI patients included between January 3rd 2024 and December 31st 2024, 372 (68.6%) had no CRM condition, 148 (27.3%) had one CRM condition (T2DM or CKD) and 22 (4.0%) had two CRM conditions (T2DM and CKD) (Figure 1A). Patients with CRM conditions were older, more often female and with greater burden of comorbidities (Figure 2). They also had a greater degree of left ventricular disfunction (as assessed by LVEF) and higher peak NT-proBNP during hospitalisation (Figure 2). Acute HF developed in 163 (30.1%) patients, with HF with reduced ejection fraction accounting for 89 (54.6%). The likelihood of developing HF progressively increased with greater number of CRM conditions compared to STEMI alone (Figure 1B). All-cause death occurred in 38 (7.0%) patients. Cumulative survival estimates varied by CRM status (Figure 1C), and the increasing complexity of CRM conditions, compared to STEMI alone, was associated with a stepwise increase in the risk of in-hospital death (Figure 1D). Conclusions CRM multimorbidity is prevalent in STEMI patients, affecting almost one-third of the study cohort. Greater CRM complexity portends worse outcomes during the initial hospitalisation, including higher risk of acute HF and in-hospital mortality, despite contemporary treatment. These findings highlight the need for early identification and implementation of disease-modifying therapies for CKD and T2DM, as part of primary prevention efforts.Fig 1.CRM comorbidities and outcomes Fig 2.Characteristics by CRM status