Contemporary heart failure and mortality burden after STEMI: insights from a real-world cohort

Background Despite advances in reperfusion, preventive medications, and guideline-directed medical therapies, patients presenting with ST-elevation myocardial infarction (STEMI) continue to encounter significant but variable risk of heart failure (HF) and mortality. Defining the contemporary burden of this residual risk and the identification of high-risk profiles in routine practice could inform risk-guided management after myocardial infarction (MI). Purpose To characterize contemporary HF and mortality outcomes in patients undergoing percutaneous coronary intervention (PCI) for STEMI and identify high-risk subgroups for targeted intervention. Methods We conducted a retrospective cohort study using Optum Market Clarity linked electronic health record and claims data (United States, July 2021–December 2023). Adults with STEMI undergoing PCI were identified. HF and mortality outcomes were assessed overall and in clinical subgroups, including anterior STEMI, anterior STEMI LAD/left main culprit vessel, and patients without prior HF or MI. Cox proportional hazards models were used to identify independent risk predictors. Results Among 63,276 STEMI patients, mean age was 64.2 years, 68.4% were male and cardiovascular risk burden was high (hypertension: 60.9%, type 2 diabetes: 32.5%, prior myocardial infarction: 6.9%). At 1 year, HF hospitalization (HHF) occurred in 8.21% (95% CI 8.00–8.43) and all-cause mortality in 8.50% (95% CI 8.29–8.72). Independent predictors of HHF included prior HF (HR 1.96, 95% CI 1.82–2.10), prior MI (HR 1.16, 95% CI 1.07–1.25), anterior STEMI (HR 1.54, 95% CI 1.47–1.63), and chronic kidney disease (HR 1.50, 95% CI 1.40–1.60). Mortality was strongly associated with cardiogenic shock (HR 2.95, 95% CI 2.77–3.14), cardiac arrest (HR 2.92, 95% CI 2.71–3.14), and anterior STEMI (HR 1.09, 95% CI: 1.04–1.15). Patients with anterior STEMI (n=25,088) represented a higher-risk group, with greater risks for HHF (10.36% [95% CI 9.98–10.74] vs 8.21%; relative increase 26%) and mortality (9.54% [95% CI 9.18–9.91] vs 8.50%; relative increase 12%) (Figure). In-hospital complications were more frequent among anterior STEMI patients, including cardiogenic shock (17.7% vs 14.5%) and HF (58.9% vs 44.5%). HF outpatient encounters were frequent, occurring in 37.5% of all patients and 50.3% of anterior STEMI patients within 1 year. Meaningful differences in event rates were observed across clinically relevant subgroups (Table). Conclusions Despite contemporary PCI and medical therapy, significant residual HF and mortality risks remain after STEMI, with anterior MI identifying a high-risk clinical group. These findings highlight the potential role of risk-guided surveillance strategies to mitigate downstream HF and mortality.