Impact of Multiple Cardiovascular Events on Long‐Term Outcomes and Bleeding Risk in Patients With Acute Coronary Syndrome: A Nationwide Population‐Based Cohort Study

Background Patients with acute coronary syndrome (ACS) are at high risk for recurrent cardiovascular events and bleeding complications, particularly in Asian populations. The long‐term impact of multiple cardiovascular events and bleeding on outcomes remains unclear. Methods Using Taiwan's National Health Insurance Research Database, this retrospective cohort study included 28 086 patients with ACS categorized into single‐event and multiple‐event groups based on cardiovascular events occurring within 2 years of the index ACS event. After matching for age, sex, and event interval, 8756 patients were assigned to the multiple‐event group and 17 446 to the single‐event group. Results The multiple‐event group had higher comorbidity rates, including hypertension, prior coronary disease, heart failure, stroke, and chronic kidney disease. Over 5 years, the multiple‐event group had significantly higher all‐cause mortality (34.0% versus 24.0%) and cardiovascular mortality (11.2% versus 5.5%) compared with the single‐event group (both P <0.0001). Major (8.4% versus 1.6%) and minor (35.5% versus 7.4%) bleeding rates were also higher (both P <0.0001). Notably, major bleeding persisted beyond 3 months in the multiple‐event group, whereas the single‐event group showed reduced bleeding after 1 month. In the multiple‐event group, each additional major bleeding event was associated with earlier subsequent cardiovascular events (coefficient=−0.2875, P =0.0325). Conclusions Patients with ACS with multiple cardiovascular events have higher rates of all‐cause mortality, cardiovascular mortality, and major bleeding than patients with ACS with a single cardiovascular event. Major bleeding may also be associated with the risk of subsequent cardiovascular events, highlighting the importance of implementing a tailored antiplatelet strategy in Asian populations.