Vora Amit N, Wang Tracy Y, Hellkamp Anne S, Thomas Laine, Henry Timothy D, Goyal Abhinav, Roe Matthew T
From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., T.Y.W., A.S.H., L.T., M.T.R.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); and Emory University School of Medicine, Atlanta, GA (A.G.).
Circ Cardiovasc Qual Outcomes. 2016 Sep;9(5):513-22. doi: 10.1161/CIRCOUTCOMES.115.002312. Epub 2016 Sep 6.
Among older patients with acute myocardial infarction (MI), it remains uncertain whether there is a time-dependent difference in the risk of recurrent mortality and nonfatal cardiovascular and cerebrovascular events for those with ST-segment-elevation MI (STEMI) compared with those with non-ST-segment-elevation MI.
Older patients ≥65 years with acute MI and significant coronary artery disease identified with coronary angiography from the ACTION Registry-GWTG (Get With the Guidelines) were linked to Medicare claims data from 2007 to 2010. We examined the unadjusted cumulative incidence of each outcome studied from hospital discharge through 2 years with log-rank tests and then performed a piece-wise proportional hazards modeling with 2 time periods: discharge to 90 days and 90 days to 2 years. Among the 46 199 patients linked with Medicare data, 17 287 (37.4%) presented with STEMI. Through 2 years, the unadjusted cumulative incidence of all-cause mortality (16.0% versus 19.8%; P<0.001) and the composite outcome (21.9% versus 27.9%; P<0.001) was lower for STEMI patients. Within the first 90 days, unadjusted rates of mortality (5.5% versus 5.3%) and the composite outcome (7.9% versus 8.1%) were similar but diverged from 90 days to 2 years (mortality, 11.1% versus 15.4%; P<0.001; composite outcome, 15.2% versus 21.5%; P<0.001). After multivariable adjustment, the adjusted risks of mortality and the composite outcome through 90 days were higher for STEMI patients, whereas risks of mortality and the composite outcome were attenuated from 90 days through 2 years.
Among older acute MI patients with angiographically confirmed coronary artery disease discharged alive, STEMI patients (compared with non-ST-segment-elevation MI patients) were found to have a lower frequency of unadjusted postdischarge mortality and composite cardiovascular and cerebrovascular outcomes through 2 years after hospital discharge. This analysis provides unique insight into differential short- and long-term risks of ischemic cardiovascular and cerebrovascular outcomes by MI classification among older MI patients with confirmed coronary artery disease surviving to hospital discharge.
在老年急性心肌梗死（MI）患者中，与非ST段抬高型心肌梗死患者相比，ST段抬高型心肌梗死（STEMI）患者在复发性死亡风险以及非致死性心血管和脑血管事件方面是否存在时间依赖性差异仍不确定。
从ACTION注册研究-GWTG（遵循指南）中通过冠状动脉造影确定的≥65岁的老年急性心肌梗死和严重冠状动脉疾病患者与2007年至2010年的医疗保险理赔数据相关联。我们通过对数秩检验检查了从出院到2年期间每个研究结局的未调整累积发生率，然后进行了分段比例风险建模，分为两个时间段：出院至90天和90天至2年。在与医疗保险数据相关联的46199例患者中，17287例（37.4%）为STEMI患者。在2年期间，STEMI患者的全因死亡率（16.0%对19.8%；P<0.001）和复合结局（21.9%对27.9%；P<0.001）的未调整累积发生率较低。在最初的90天内，死亡率（5.5%对5.3%）和复合结局（7.9%对8.1%）的未调整发生率相似，但从90天到2年出现差异（死亡率，11.1%对15.4%；P<0.001；复合结局，15.2%对21.5%；P<0.001）。多变量调整后，STEMI患者在90天内的死亡率和复合结局调整风险较高，而从90天到2年，死亡率和复合结局风险降低。
在出院存活的经血管造影证实患有冠状动脉疾病的老年急性心肌梗死患者中，发现STEMI患者（与非ST段抬高型心肌梗死患者相比）在出院后2年内未调整的出院后死亡率以及心血管和脑血管复合结局的发生率较低。该分析为确诊冠状动脉疾病并存活至出院的老年心肌梗死患者中，根据心肌梗死分类对缺血性心血管和脑血管结局的短期和长期差异风险提供了独特见解。
