Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
PLoS Med. 2018 Mar 6;15(3):e1002501. doi: 10.1371/journal.pmed.1002501. eCollection 2018 Mar.
There is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI.
This national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population.
Multimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes.
ClinicalTrials.gov NCT03037255.
对于患有急性心肌梗死（AMI）的患者，关于多种合并症的规模和影响的知识有限。因此，本研究旨在确定多种合并症与 AMI 后长期生存之间的关联程度。
本项全国性观察性研究纳入了 2003 年 1 月 1 日至 2013 年 6 月 30 日期间因 AMI 入住英国和威尔士心肌血运重建计划的 693388 名患者（中位年龄 70.7 岁，452896[65.5%]为男性）。在 AMI 发病时，412809 名（59.5%）患者患有多种合并症，即至少有以下 1 种长期健康状况：糖尿病、慢性阻塞性肺疾病或哮喘、心力衰竭、肾衰竭、脑血管病、外周血管疾病或高血压。心力衰竭、肾衰竭或脑血管病患者的预后最差（每 100 人年分别为 39.5[95%CI 39.0-40.0]、38.2[27.7-26.8]和 26.6[25.2-26.4]死亡）。潜在类别分析显示出 3 种多种合并症表型聚类：（1）高多种合并症类，伴有心力衰竭、外周血管疾病和高血压；（2）中多种合并症类，伴有外周血管疾病和高血压；（3）低多种合并症类。与类别 2 和 3 患者相比，类别 1 患者接受药物治疗的可能性较低（包括阿司匹林分别为 83.8%、87.3%和 87.2%；β-受体阻滞剂分别为 74.0%、80.9%和 81.4%；他汀类药物分别为 80.6%、85.9%和 85.2%）。灵活参数生存模型表明，与类别 3 患者相比，类别 1 和类别 2 患者的死亡风险分别增加了 2.4 倍（95%CI 2.3-2.5）和 1.5 倍（95%CI 1.4-1.5），预期寿命损失分别为 2.89 年和 1.52 年，类别 1 和类别 2 患者的预期寿命损失分别为 2.89 年和 1.52 年。研究仅关注全因死亡率，因为缺乏可用的特定病因死亡率数据。然而，通过根据多种合并症表型聚类与一般年龄、性别和年份匹配人群相比，提供 AMI 后预期寿命损失，我们确定了与死亡率有明确关联的疾病特异性因素。
AMI 患者的多种合并症很常见，并且与死亡风险的累积增加相关。确定了与预期寿命损失显著相关的 3 种多种合并症表型聚类，这应该是改善心血管结局的联合治疗目标。
ClinicalTrials.gov NCT03037255。
