Key result
Contemporary management linked to ~25% lower 1-year MACE risk vs historical care in post-MI patients.
Why the study?
Whether elderly patients and those with prior comorbidities at highest risk after myocardial infarction benefit from contemporary management was not fully elucidated.
Does implementation of contemporary guideline-directed management improve short- and long-term cardiovascular outcomes in high-risk post-MI patients undergoing PCI?
Cohort (n=2,053)
No
Does implementation of contemporary guideline-directed management improve short- and long-term cardiovascular outcomes in high-risk post-MI patients undergoing PCI?
Hazard Ratio: 0.75 (95% CI 0.62–0.91)
p-value: p=0.004
Advancements in contemporary guideline-directed management, including greater use of drug-eluting stents and potent antiplatelets, are associated with significantly improved clinical outcomes among high-risk patients surviving an acute myocardial infarction.
Contemporary management was associated with lower 1-year MACE; leaves open causal benefits and need for randomized confirmation in high-risk post-MI patients.
BACKGROUND: Patients with myocardial infarction (MI) are at increased risk for recurrent cardiovascular events, yet some patients, such as the elderly and those with prior comorbidities, are particularly at the highest risk. Whether these patients benefit from contemporary management is not fully elucidated. METHODS: Included were consecutive patients with MI who underwent percutaneous coronary intervention (PCI) in a large tertiary medical center. Patients were stratified according to the thrombolysis in myocardial infarction (TIMI) risk score for secondary prevention (TRS2°P) to high (TRS2°P = 3), very high (TRS2°P = 4), or extremely high-risk (TRS2°P = 5-9). Excluded were low and intermediate-risk patients (TRS2°P < 3). Outcomes included 30-day/1-year major adverse cardiac events (MACE) and 1-year mortality. Temporal trends were examined in the early (2004-2010) and late (2011-2016) time-periods. RESULTS: Among 2053 patients, 50% were high-risk, 30% very high-risk and 20% extremely high-risk. Extremely high-risk patients were older (age 74 ± 10 year) and had significant comorbidities (chronic kidney disease 68%, prior CABG 40%, heart failure 78%, peripheral artery disease 29%). Drug-eluting stents and potent antiplatelets were more commonly used over time in all risk-strata. Over time, 30-day MACE rates have decreased, mainly attributed to the very high (11.3% to 5.1%, p = .006) and extremely high-risk groups (15.9% to 8.0%, p = .016), but not the high-risk group, with similar quantitative results for 1-year MACE. The rates of 1-year mortality remained unchanged in either group. CONCLUSION: Within a particularly high-risk cohort of MI patients who underwent PCI, the implementation of guideline-recommended therapies has improved over time, with the highest-risk groups demonstrating the greatest benefit in outcomes.
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Grinberg et al. (2021) conducted a cohort in Myocardial infarction (n=2,053). Late time-period (2011-2016) contemporary management vs. Early time-period (2004-2010) management was evaluated on 1-year major adverse cardiac events (MACE: composite of death, MI, stroke, or unstable angina) (HR 0.75, 95% CI 0.62-0.91, p=0.004). Compared with the early period, contemporary management in the late period significantly reduced the risk of 1-year major adverse cardiac events by 25% (HR 0.75) in high-risk post-MI patients.
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