Increased Mortality Associated With Low Use of Clopidogrel in Patients With Heart Failure and Acute Myocardial Infarction Not Undergoing Percutaneous Coronary Intervention

H eart failure (HF) represents a major and growing public health problem because of its prevalence, incidence, morbidity, mortality, and economic costs. The prevalence of HF is 2% to 3% of the general population. 1 Five million Americans are affected, with Ͼ550 000 cases diagnosed each year. 2 The mortality rate from severe HF remains Ͼ60% within 5 years of diagnosis, and 50% of hospitalized patients with HF require readmission within 6 months of discharge. In the US estimated costs amount to Ͼ $35 billion per year. 3 Although several therapies (eg, ␤-blockers, angiotensinconverting enzyme [ACE] inhibitors, and cardiac resynchronization therapy) have been proven effective in improving HF outcomes, many unanswered questions about optimal treatment remain. One area of ongoing uncertainty is the appropriate role for antithrombotic therapy in patients with HF. Observational data suggest that patients with HF have an increased venous thromboembolism (VTE) risk (deep venous thromboembolism [DVT], pulmonary embolism [PE], peripheral arterial thromboembolism, and stroke). 4 These epidemiological findings are supported by multiple mechanisms that can contribute to a hypercoagulable state in patients with HF. Despite this increased risk of VTE, the role of antithrombotic therapy remains unclear. In this article, we provide an overview of epidemiology, pathophysiology, clinical trial data, and therapeutic recommendations for prevention of thromboembolism in HF. Search StrategyWe searched PubMed for articles published between 1958 and 2010 using the following search terms: epidemiology of heart failure, thromboembolism and heart failure, thrombogenesis and heart failure, anticoagulation in heart failure, antiplatelet agent and heart failure, aspirin and heart failure, bleeding risk and anticoagulation, and aspirin and angiotensin-converting enzyme inhibitors. We also studied abstracts from national and international cardiovascular meetings to identify unpublished studies using the key words anticoagulation and dilated cardiomyopathy. EpidemiologyData from published observational studies and secondary analyses of randomized controlled trials (RCTs) indicate that patients with HF patients have a higher risk for VTE than the general population. Observational CohortsDVT and PE Several case-cohort studies have shown that HF is associated with a 2-to 3-fold increased risk of DVT and PE compared with other medical conditions. 5 Retrospective analyses report an annual VTE incidence of 1.0% to 4.5% in patients with HF. 6 In RCTs of thromboprophylaxis in hospitalized patients with HF followed for 90 days, DVT rates ranged from 4.0% to 14.6%. 7,8 The Prophylaxis in Medical Patients With Enoxaparin trial evaluated VTE incidence in hospitalized patients with (nϭ353) and without (nϭ749) HF during a follow-up of 14 days after discharge and found that 15% of patients with HF not treated with enoxaparin developed VTE. 9 Beemath et al, 4 using data from the National Hospital Discharge Survey, found an increased risk of VTE in hospitalized p...

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Section: Current Guidelines and Practical Recommendationsmentioning

confidence: 99%

Thromboembolism and Antithrombotic Therapy in Patients With Heart Failure in Sinus Rhythm

Bettari

Fiuzat

Becker

et al. 2011

Circ: Heart Failure

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“…Elevated initial total cholesterol levels in our study had also a significant relation to MACE rates. PRIAMHO II registry of Aros et al (2006) and other studies (Elwood and Sweetnam, 1979;COMMIT, 2005;De Luca et al, 2006;Banerjee et al, 2008;Bonde et al, 2010) proved that B-blokers, statins, clopidogrel, acetylsalisylic acid and ACE inhibitors prescribed on discharge lowered the mortality and MACE rates of first year, significantly. As these medications were prescribed to all ACS patients of our study in accordance to indications and contraindications, no significant difference was found between medical treatment strategies of MACE and non-MACE groups.…”

Section: Discussionmentioning

confidence: 93%

Relationship between cardiovascular evaluation data on admission and secondary adverse cardiac event rate after acute coronary syndrome

Civan¹,

Özcan²,

Zıyrek³

et al. 2014

jecm

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Article HistoryReceived 30 / 10 / 2013 Accepted 08 / 06 / 2014The current study aimed to investigate the relationship of clinical data with mean platelet volume (MPV) and QT dispersion values on admission of acute coronary syndrome (ACS) patients to the adverse cardiac event rate in a follow-up period of 20 months after discharge. For this purpose demographic and clinical data with corrected QT dispersion on admission and MPV values of 97 consequtive patients with ACS were recorded, retrospectively. Their history of major adverse cardiac event (MACE) in a 20 months period after ACS was obtained from the hospital records, interviews with the attending physicians and telephone calls to patients. Demographic and clinical data with corrected QT dispersion on admission, and MPV values were compared between groups with and without MACE in terms of statistical significance. In our study, diabetesmellitus, left ventricular ejection fraction (EF) and wall motion score index (WMSI), corrected QT dispersion, total cholesterol, LDL, CK-MB and troponin levels were found significantly related to the secondary MACE rate (p values; 0.046, 0.0001, 0.0001, 0.032, 0.024, 0.002 and 0.0001, respectively). No significant relation was detected between groups with and without MACE in terms of conservative medical follow-up and revascularization history (p=0.774). In the comparison of mean MPV values, there was no statistically significant difference between MPV values of patients with MACE (10.4±1.8 fl) and without MACE (10.3±2 fl) (p=0.799). In addition, the subgroup analysis on acute ST-elevation myocardial infarction cases in our study group did not state a significant relationship between MPV values below/above 10.3 fl and MACE rates (p=0.774). Finally, this retrospective study showed that corrected QT dispersion, diabetes, contractile reserve of left ventricule, total and LDL-cholesterol and peak cardiac enzyme values assessed during ACS might predict MACE.

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“…In a recent analysis of the French registry of FAST‐MI (Acute ST‐ and Non‐ST‐Elevation Myocardial Infarction),13 statins were associated with decreased mortality post‐MI, even after 5 years from the event. Clopidogrel also confers cardiovascular protection and lowers mortality following an ACS,14 even in patients not undergoing a percutaneous coronary intervention 15. Nevertheless, BB conferred protection even after taking into account those variables.…”

Section: Discussionmentioning

confidence: 99%

β‐Blocker Therapy Prior to Admission for Acute Coronary Syndrome in Patients Without Heart Failure or Left Ventricular Dysfunction Improves In‐Hospital and 12‐Month Outcome: Results From the GULF‐RACE 2 (Gulf Registry of Acute Coronary Events‐2)

Khalil

AlHabib

Singh

et al. 2017

JAHA

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BackgroundThe prognostic impact of β‐blockers (BB) in acute coronary syndrome (ACS) patients without heart failure (HF) or left ventricular dysfunction is controversial, especially in the postreperfusion era. We sought to determine whether a BB therapy before admission for ACS has a favorable in‐hospital outcome in patients without HF, and whether they also reduce 12‐month mortality if still prescribed on discharge.Methods and ResultsThe GULF‐RACE 2 (Gulf Registry of Acute Coronary Events‐2) is a prospective multicenter study of ACS in 6 Middle Eastern countries. We studied in‐hospital cardiovascular events in patients hospitalized for ACS without HF in relation to BB on admission, and 1‐year mortality in relation to BB on discharge. Among the 7903 participants, 7407 did not have HF, of whom 5937 (80.15%) patients were on BB. Patients on BB tended to be older and have more comorbidities. However, they had a lower risk of in‐hospital mortality, mitral regurgitation, HF, cardiogenic shock, and ventricular tachycardia/ventricular fibrillation. Furthermore, 4208 patients were discharged alive and had an ejection fraction ≥40%. Among those, 84.1% had a BB prescription. At 12 months, they also had a reduced risk of mortality as compared with the non‐BB group. Even after correcting for confounding factors in 2 different models, in‐hospital and 12‐month mortality risk was still lower in the BB group.ConclusionsIn this cohort of ACS, BB therapy before admission for ACS is associated with decreased in‐hospital mortality and major cardiovascular events, and 1‐year mortality in patients without HF or left ventricular dysfunction if still prescribed on discharge.

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Increased Mortality Associated With Low Use of Clopidogrel in Patients With Heart Failure and Acute Myocardial Infarction Not Undergoing Percutaneous Coronary Intervention

Abstract: Clopidogrel was associated with reduced mortality in patients with HF who do not undergo PCI after their first-time AMI, whereas this association was not apparent in patients without HF. Further studies of the benefit of clopidogrel in patients with HF and AMI are warranted.

Cited by 20 publications

References 28 publications

Thromboembolism and Antithrombotic Therapy in Patients With Heart Failure in Sinus Rhythm

Thromboembolism and Antithrombotic Therapy in Patients With Heart Failure in Sinus Rhythm

Relationship between cardiovascular evaluation data on admission and secondary adverse cardiac event rate after acute coronary syndrome

β‐Blocker Therapy Prior to Admission for Acute Coronary Syndrome in Patients Without Heart Failure or Left Ventricular Dysfunction Improves In‐Hospital and 12‐Month Outcome: Results From the GULF‐RACE 2 (Gulf Registry of Acute Coronary Events‐2)

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