Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes

Abstract

Background— Few data are available on the impact of heart failure (HF) across all types of acute coronary syndromes (ACS). Methods and Results— The Global Registry of Acute Coronary Events (GRACE) is a prospective study of patients hospitalized with ACS. Data from 16 166 patients were analyzed: 13 707 patients without prior HF or cardiogenic shock at presentation were identified. Of these, 1778 (13%) had an admission diagnosis of HF (Killip class II or III). HF on admission was associated with a marked increase in mortality rates during hospitalization (12.0% versus 2.9% [with versus without HF], P <0.0001) and at 6 months after discharge (8.5% versus 2.8%, P <0.0001). Of note, HF increased mortality rates in patients with unstable angina (defined as ACS with normal biochemical markers of necrosis; mortality rates: 6.7% with versus 1.6% without HF at admission, P <0.0001). By logistic regression analysis, admission HF was an independent predictor of hospital death (odds ratio, 2.2; P <0.0001). Admission HF was associated with longer hospital stay and higher readmission rates. Patients with HF had lower rates of catheterization and percutaneous cardiac intervention, and fewer received β-blockers and statins. Hospital development of HF (versus HF on presentation) was associated with an even higher in-hospital mortality rate (17.8% versus 12.0%, P <0.0001). In patients with HF, in-hospital revascularization was associated with lower 6-month death rates (14.0% versus 23.7%, P <0.0001; adjusted hazard ratio, 0.5; 95% CI, 0.37 to 0.68, P <0.0001). Conclusions— In this observational registry, heart failure was associated with reduced hospital and 6-month survival across all ACS subsets, including patients with normal markers of necrosis. More aggressive treatment of these patients may be warranted to improve prognosis.

Aldosterone blockade in post‐acute myocardial infarction heart failure

“…[3][4][5][6][7] It is estimated that 20 to 40% of patients with AMI will develop HF. 3,4,7 Patients post AMI with HF and/or LVSD have a 3-to 4-fold increased risk of in-hospital death, as well as significant increases in 30-day mortality, long-term mortality, and rehospitalization rates compared with patients with AMI and without HF.…”

“…[3][4][5][6][7] It is estimated that 20 to 40% of patients with AMI will develop HF. 3,4,7 Patients post AMI with HF and/or LVSD have a 3-to 4-fold increased risk of in-hospital death, as well as significant increases in 30-day mortality, long-term mortality, and rehospitalization rates compared with patients with AMI and without HF. [3][4][5][6] Recently, it has been shown that the first 30 days post infarction is the period of highest risk in patients with LVSD, especially for sudden cardiac death (Fig.…”

“…Despite serious risks of mortality and hospitalizations associated with development of HF and/or LVSD in patients with AMI, [3][4][5][6] these patients are less likely to be treated with lifesaving, guideline-recommended therapies than those with AMI and without HF. 3,4 Wu et al 4 demonstrated that 75% of patients with AMI and HF were not treated with ACE inhibitors or beta blockers, and 25% did not receive aspirin, although these treatments provided the strongest protection against in-hospital death in patients with HF (odds ratio 0.51, 0.42, and 0.42 for ACE inhibitor, beta blocker, and aspirin, respectively).…”

“…3,4 Wu et al 4 demonstrated that 75% of patients with AMI and HF were not treated with ACE inhibitors or beta blockers, and 25% did not receive aspirin, although these treatments provided the strongest protection against in-hospital death in patients with HF (odds ratio 0.51, 0.42, and 0.42 for ACE inhibitor, beta blocker, and aspirin, respectively). Treatment rates for patients with AMI without HF were significantly better (p < 0.001) (Fig.…”

Hospital protocols and evidence‐based therapies: The importance of integrating aldosterone blockade into the management of patients with post—acute myocardial infarction heart failure

“…1 The presence of HF in the patient post AMI greatly increases the risk for adverse clinical outcomes. The development of HF is associated with a significantly higher mortality during hospitalization for AMI, 2,3 at 30 days post AMI, 1 and at 6 months after discharge. 2 In addition, patients with HF have increased lengths of hospital stay for AMI by approximately 2 days and a greater readmission rate than patients without HF.…”