Search

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjmed.2006.05.056 Byline: Wei-Ching Chang, Padma Kaul, Cynthia M. Westerhout, Michelle M. Graham, Paul W. Armstrong Keywords: Acute myocardial infarction; Socioeconomic status; Emergency department; Revascularization Abstract: To assess the effects of socioeconomic status on mortality in patients with acute myocardial infarction. Author Affiliation: University of Alberta, Edmonton, Alberta, Canada. Article Note: (footnote) This study was supported by a grant from the Canadian Institute of Health Research. Although the study is based in part on data provided by Alberta Health and Wellness, the interpretation and conclusions contained herein are those of the researchers and do not necessarily represent the views of the Government of Alberta. Neither the Government nor Alberta Health and Wellness express any opinion in relation to this study.

Aims: The STREAM study randomly assigned ST-elevation myocardial infarction (STEMI) patients to receive a pharmacoinvasive versus primary percutaneous coronary intervention reperfusion strategy. We assessed whether there was an association between outcomes based on randomisation at a community hospital versus a prehospital location.Methods/results: Community hospital patients (358/1866 (19.2%)) were compared to prehospital patients and their outcomes categorised into pharmacoinvasive according to their treatment assignment. Compared to prehospital patients, community hospital patients had more diabetes (17.8% vs. 11.5%, P=0.001), higher Killip Class >1 (9.4% vs. 5.0%, P=0.002) and thrombolysis in myocardial infarction risk scores ⩾5 (18.2% vs. 12.4%, P=0.005). The 30-day primary endpoint (death, shock, congestive heart failure and re-infarction) for community hospital patients was 14.9% versus 13.2% for prehospital patients (P=0.403). Community hospital pharmacoinvasive patients tended to receive less rescue (35.1% vs. 42.8%, P=0.062); when deployed their rescue was delayed 43 minutes. Community hospital patients undergoing primary percutaneous coronary intervention experienced a delay of 31 minutes versus prehospital patients. Pharmacoinvasive patients receiving scheduled angiography from a community hospital and prehospital patients had comparable times to angiography (17.7 vs. 18.7 hours) and low event rates (6.2% vs. 8.0%). Although the interaction between randomisation location and treatment received on the primary endpoint was not significant (Pinteraction=0.065) those pharmacoinvasive patients requiring rescue from community hospitals had worse outcomes than prehospital rescue patients (odds ratio 2.28, 95% confidence interval 1.16–4.49).Conclusion: Within STREAM, STEMI patients randomly assigned at community hospitals had a higher baseline risk but similar outcomes compared to those studied prehospital patients irrespective of successful pharmacoinvasive therapy or primary percutaneous coronary intervention. However, worse outcomes in the pharmacoinvasive patients requiring rescue in community hospitals emphasises their need for immediate transfer to a percutaneous coronary intervention-capable hospital.

Background:Both patient age and sex influence heart failure (HF) treatment and outcomes. Given women are generally older in HF trials, we examined the associations of age and sex with clinical characteristics, background HF therapy, and response to vericiguat in VICTORIA. VICTORIA enrolled 5050 patients with HF with reduced ejection fraction (HFrEF) and recent worsening HF, was broadly inclusive without an upper age limit, and included 28% women (n=1208), and 31% (1568 ) were ≥75 years old with event rates exceeding most HF trials.Methods:Clinical characteristics were compared across age groups (<65, 65 to <75, ≥75 and <75, ≥75 years) and sex (Table).Results:More women (37%) than men (29%) were age ≥75 years. Compared with younger patients, those ≥75 had higher EF and class III/IV symptoms, more comorbidities, higher NT-proBNP and lower eGFR, indicative of more advanced disease; however, this age group had the lowest use of triple therapy. Within each age group, women had higher EF and lower burden of some comorbidities (atrial fibrillation, hyperlipidemia, coronary artery disease) compared with men, but similar functional status and NT-proBNP. There were no sex differences in the use of triple therapy by age group; however, women ≥75 years less often achieved target doses of triple therapy than men of similar age. Women were also less likely to receive HF devices across all ages. The incidence of the primary composite endpoint (cardiovascular death or HF hospitalization) increased across age groups and was higher in men than women. Compared with the pre-specified age subgroup analysis (i.e., <75, ≥75 years), the beneficial effect of vericiguat on the primary endpoint was not modified by age (continuous) and sex (3-way interaction; p=0.847).Conclusions:Women in VICTORIA were older than men, and while elderly women received less intense background HF therapy, their prognosis was nominally better than elderly men. Vericiguat’s benefit was independent of age and sex.

Background:In the VICTORIA trial in patients with heart failure with reduced ejection fraction, vericiguat (V) versus placebo (P) reduced the primary composite outcome (heart failure hospitalization [HFH] or cardiovascular death [CVD]) from 38.5 to 35.5% (1869 events: V=897, P=972) (Fig A). In this prespecified analysis, we assessed vericiguat’s treatment effect using weighted composite endpoint (WCEP) and win-ratio (WR) methods.Methods:Clinical events were centrally adjudicated. A survey of 37 international trial leaders conducted before database lock led to the derivation of relative weights of subtypes of HFH (mild [change in therapy] 0.39; moderate [requiring IV diuresis] 0.50; severe [urgent deterioration requiring inotropic support] 0.67) and CVD (1.0). A WCEP model estimated the effect of vericiguat on mean survival after severity-weighting recurrent HFH events and CVD. The unmatched WR approach, which accounted for recurrent HFH events, was applied with the hierarchy of HFH

Background:Patients with chronic heart failure with reduced ejection fraction (HFrEF) and recent decompensation are at high risk of cardiovascular (CV) events including mortality; risk stratification remains challenging. To further assess risk in this population, we characterized their baseline 12-lead ECGs and their prognostic value in 4880 patients (24% female) from the VICTORIA study.Methods:Baseline ECG parameters were interpreted in a core laboratory blinded to centrally adjudicated clinical outcomes. There were 1799 primary composite events (time to first HF hospitalization (HFH) or CV death) and 1005 total all-cause deaths (21% sudden). The MAGGIC-adjusted association between baseline ECG parameters and outcomes are presented as hazard ratio (HR) and 95% confidence intervals (CIs).Results:Incidence rates of baseline ECG parameters and their association with all-cause death and the primary composite outcome are shown below. The median MAGGIC score was 24 (19, 28) points. Higher heart rate, greater QRS duration, and prolonged QTc were significantly associated with the primary composite and all-cause death (Table), as well as for CV death ([HR 1.04, 95% CI 1.02-1.07; p<0.001] [HR 1.02, 1.00-1.04; p=0.015] [HR 1.16, 1.00-1.34; p=0.049]), respectively. Sex-based interactions were evident for contiguous Q waves on all-cause death (male: HR 0.98, 0.82-1.17; female: HR 1.56, 1.15-2.12; interaction p=0.010) and CV death (male: HR 1.03, 0.85-1.25; female: HR 1.66, 1.17-2.34; interaction p=0.019). Additionally, contiguous Q-waves were associated with sudden death (HR 1.45, 1.05-2.00; p=0.022) and appeared to double the risk in females (male: HR 1.25, 0.87-1.79; female: HR 2.50, 1.23-5.06; interaction p= 0.087).Conclusion:Routine ECG parameters are associated with worse outcomes in high risk HFrEF patients—particularly in females with contiguous Q waves.

Aims: Little is known regarding consequences of frailty in patients with acute coronary syndrome (ACS). We assessed the associations of frailty and outcomes in ACS patients who were participating in a clinical trial.Methods and results: The TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes (TRILOGY ACS) trial randomized 9326 patients planned for medical management to prasugrel or clopidogrel. The primary endpoint was a composite of cardiovascular death, myocardial infarction (MI), or stroke over a period of 30 months. A frailty score based upon the Fried score was self-reported at baseline in patients aged ?65 years. Five frailty questions were recorded for 4996/5102 (97.9%) patients: 72.3% were classified as not-frail (0 items), 23.0% as pre-frail (1–2 items), and 4.7% as frail (?3 items). Increasing frailty score was associated with older age, diabetes, and higher Global Registry of Acute Coronary Events (GRACE) scores. Frailty was associated with a higher unadjusted incidence of the primary endpoint (pre-frail vs not-frail: 29.2% vs 23.1%; hazard ratio [HR]: 1.39; 95% confidence interval [CI]: 1.19–1.61; p<0.001; frail vs not-frail: 39.7% vs 23.1%; HR: 1.76; 95% CI: 1.36–2.28; p<0.001), and all-cause mortality (pre-frail vs not-frail: 21.7% vs 15.0%; HR: 1.45; 95% CI: 1.22–1.73; p<0.001; frail vs not-frail: 30.2% vs 15.0%; HR: 1.98; 95% CI: 1.47–2.68; p<0.001). After adjustment for baseline characteristics and GRACE covariates, frailty remained independently associated with the primary endpoint: pre-frail vs not-frail, HR: 1.33; 95% CI: 1.15–1.54; p<0.001; frail vs not-frail, HR: 1.52; 95% CI: 1.18–1.98; p=0.002. There was no association of frailty with bleeding.Conclusion: Frailty is associated with the composite of cardiovascular death, MI, or stroke. Frailty assessment contributes to risk prediction and adds to the GRACE score.