Underutilization of invasive management and its association with long-term outcomes in cancer patients with acute myocardial infarction

Background Patients with cancer who develop acute myocardial infarction (AMI) are frequently managed conservatively due to concerns regarding competing mortality risks and bleeding. The long-term benefit of invasive management, particularly percutaneous coronary intervention (PCI), in this population remains uncertain. Purpose To evaluated the utilization of invasive strategies and the association of PCI with long-term cardiovascular and cancer-specific outcomes in patients with AMI and cancer. Methods This longitudinal cohort study included 500,876 UK Biobank participants (54.4% women) enrolled between 2006–2010, with follow-up to October 31, 2022 (median 14.0 years). Among 68,873 participants diagnosed with cancer, 3,121 developed AMI (1,529 post-cancer AMI). The primary outcome was major adverse cardiac and cerebrovascular events (MACCE). Analyses included propensity score matching (PSM) for PCI/CABG versus no revascularization and competing risk models for cause-specific mortality. Results Patients with post-cancer AMI were significantly less likely to undergo coronary angiography, PCI, or CABG compared with patients without prior cancer (p<0.01, respectively), with the lowest PCI utilization observed in those with metastatic disease (40.1% vs. 72.8% in non-metastatic, p<0.01). After propensity matching, PCI was associated with significant reductions in long-term mortality and MACCE in both STEMI and NSTEMI presentations, irrespective of metastatic status (all p<0.05). In competing-risk analyses, PCI was independently associated with lower cardiovascular mortality (HR 0.69, 95% CI 0.56–0.87) and cancer-specific mortality (HR 0.61, 95% CI 0.53–0.71). Older age, frailty, smoking, socioeconomic deprivation, and cardiometabolic comorbidities were independent predictors of adverse outcomes, according to multivariable Cox regression analyses. Conclusions Cancer patients with AMI experience markedly worse long-term outcomes and are less likely to receive invasive management, particularly post-cancer AMI with metastasis. PCI is associated with significant long-term reductions in both cardiovascular and cancer-related mortality, including in advanced malignancy. These findings support consideration of an invasive strategy in appropriately selected cancer patients presenting with AMI.