Aims Left ventricular ejection fraction (LVEF) ≤ 40% is a well-established risk factor for mortality after acute coronary syndromes (ACS). However, the long-term prognostic impact of mildly reduced ejection fraction (EF) (LVEF 41-49%) after ACS remains less clear. Methods and resultsThis was a retrospective study enrolling patients admitted with ACS included in a single-centre databank. LVEF was assessed by echocardiography during index hospitalization. Patients were divided in the following categories according to LVEF: normal (LVEF ≥ 50%), mildly reduced (LVEF 41-49%), and reduced (LVEF ≤ 40%). The endpoint of interest was all-cause death after hospital discharge. A multivariable Cox model was used to adjust for confounders. A total of 3200 patients were included (1952 with normal EF, 375 with mildly reduced EF, and 873 with reduced EF). The estimated cumulative incidence rates of mortality at 10 years for patients with normal, mildly reduced, and reduced EF were 24.8%, 33.5%, and 41.3%, respectively. After adjustments, the presence of reduced EF was associated with higher mortality compared with normal EF [adjusted hazard ratio (HR) 1.64; 95% confidence interval (CI) 1.36-1.96; P < 0.001], as was mildly reduced EF compared with normal EF (adjusted HR 1.33; 95% CI 1.05-1.68; P = 0.019). The presence of reduced EF was not associated with a statistically significantly higher mortality compared with mildly reduced EF (adjusted HR 1.23; 95% CI 0.96-1.57; P = 0.095). Conclusions In patients with ACS, mildly reduced EF measured in the acute phase was associated with higher long-term mortality compared with patients with normal EF. These data emphasize the importance of anti-remodelling therapies for ACS patients who have LVEF in the mildly reduced range.
Introduction: There are scarce data in the literature analyzing, in patients with acute myocardial infarction (AMI), the impact of right (RBBB) and left bundle-branch block (LBBB) on mortality, especially in the long-run after hospital discharge. Hypothesis: RBBB and LBBB is associated with in-hospital and long-term mortality in patients with AMI. Methods: Retrospective analysis from an administrative databank of patients (pts) with acute coronary syndromes, collected prospectively between 1998 and 2016. From a total of 6466 pts, we selected 2895 with AMI (72% men, mean age 63.7 years, 50% with ST-segment-elevation AMI) and complete follow-up for up to 17 years (mean 5.5 years). In-hospital and long-term mortality was compared with RBBB (incidence=5.8%) and LBBB (incidence=3.9%) in models unadjusted and adjusted for 14 variables including age, type/location of AMI and in-hospital cardiogenic shock. Results: In-hospital mortality was 15.5% vs. 7.0% for pts with or without RBBB, respectively (OR=2.41, P<0.001; adj. OR=1.32, 0.37); for pts with of without LBBB the percentages were 14.2% vs. 7.3%, respectively (OR=2.10, P=0.008, adj. OR=1.13, P=0.74). The results for the long-term follow-up are depicted in the figure. Conclusions: After adjustments, there was no association between RBBB or LBBB with higher in-hospital death among patients with AMI. On the other hand, in the long-term follow-up LBBB, but not RBBB, showed significant and independent association with higher mortality.
Introduction: Left ventricle ejection fraction (LVEF) is a well-established marker for survival after acute coronary syndromes (ACS). While there has been strong association between low ejection fraction (i.e., LVEF < 40%) and mortality, the long-term prognostic impact of mid-range EF (LVEF 40-49%) after ACS remains less clear. Methods: This was a retrospective study enrolling consecutive patients admitted with ACS included in a single tertiary center databank. LVEF was assessed by echocardiography during index hospitalization. Patients were divided in the following categories according to LVEF: normal (LVEF ≥ 50%), mid-range (40-49%) and low (< 40%). The endpoint of interest was all-cause death after hospital discharge. A multivariable Cox regression model was used to adjust for confounders. The model was adjusted for age, sex, race, history of diabetes mellitus, prior HF, arterial hypertension, dyslipidemia, smoking, STEMI versus non-ST elevation ACS, prior MI, prior PCI, prior CABG, creatinine and Killip class at admission Results: A total of 3200 patients were included (1,952 with normal EF; 659 with mid-range EF and 589 with low EF); mean age was 63.5 ± 12.4 years (63.2±12.3, 63.9±12.7 and 64.2±12.4 years, respectively for normal, mid-range and low EF; p = 0.14); 2216 (69.3%) were male and 1257 (39.3%) presented with STEMI. The median follow-up time was 5 years, and the maximum follow-up time was 17.8 years. Overall results are shown in the Figure 1. In a sensitivity analysis using a different definition for mid-range EF (36-54%), results remained similar (data not shown). Conclusion: In ACS patients discharged alive from hospital, mid-range EF measured in the acute phase was associated with increased long-term mortality compared to patients with normal EF. This magnitude of effect was similar to that observed for patients with low EF. These data reinforce the need to consider anti-remodeling therapies also for ACS patients who have LVEF in the mid-range.
OBJECTIVES: Returning to work after an episode of acute coronary syndrome (ACS) is challenging for many patients, and has both personal and social impacts. There are limited data regarding the working status in the very long-term after ACS. METHODS: We retrospectively analyzed 1,632 patients who were working prior to hospitalization for ACS in a quaternary hospital and were followed-up for up to 17 years. Adjusted models were developed to analyze the variables independently associated with actively working at the last contact, and a prognostic predictive index for not working at follow-up was developed. RESULTS: The following variables were significantly and independently associated with actively working at the last contact: age>median (hazard-ratio [HR], 0.76, p <0.001); male sex (HR, 1.52, p <0.001); government health insurance (HR, 1.36, p <0.001); history of angina (HR, 0.69, p <0.001) or myocardial infarction (MI) (HR, 0.76, p =0.005); smoking (HR, 0.81, p =0.015); ST-elevation MI (HR, 0.81, p =0.021); anterior-wall MI (HR, 0.75, p =0.001); non-primary percutaneous coronary intervention (PCI) (HR, 0.77, p =0.002); fibrinolysis (HR, 0.61, p <0.001); cardiogenic shock (HR, 0.60, p =0.023); statin (HR, 3.01, p <0.001), beta-blocker (HR, 1.26, p =0.020), angiotensin-converting enzyme (ACE) inhibitor/angiotensin II receptor blocker (ARB) (HR, 1.37, p =0.001) at hospital discharge; and MI at follow-up (HR, 0.72, p =0.001). The probability of not working at the last contact ranged from 24.2% for patients with no variables, up to 80% for patients with six or more variables. CONCLUSIONS: In patients discharged after ACS, prior and in-hospital clinical variables, as well as the quality of care at discharge, have a great impact on the long-term probability of actively working.
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