Division of Cardiology University of British Columbia Vancouver BC Canada.
TIMI Study GroupBrigham and Women's Hospital Boston MA.
J Am Heart Assoc. 2022 Feb 15;11(4):e022733. doi: 10.1161/JAHA.121.022733. Epub 2022 Feb 3.
Background Unlike patients with low ejection fraction after an acute coronary syndrome (ACS), little is known about the long-term incidence and influence of cardiovascular events before sudden death among stabilized patients after ACS. Methods and Results A total of 18 144 patients stabilized within 10 days after ACS in IMPROVE-IT (Improved Reduction of Outcomes: Vytorin Efficacy International Trial) were studied. Cumulative incidence rates (IRs) and IRs per 100 patient-years of sudden death were calculated. Using Cox proportional hazards, the association of ≥1 additional postrandomization cardiovascular events (myocardial infarction, stroke, and hospitalization for unstable angina or heart failure) with sudden death was examined. Early (≤1 year after ACS) and late sudden deaths (>1 year) were compared. Of 2446 total deaths, 402 (16%) were sudden. The median time to sudden death was 2.7 years, with 109 early and 293 late sudden deaths. The cumulative IR was 2.47% (95% CI, 2.23%-2.73%) at 7 years of follow-up. The risk of sudden death following a postrandomization cardiovascular event (150/402 [37%] sudden deaths; median 1.4 years) was greater (IR/100 patient-years, 1.45 [95% CI, 1.23-1.69]) than the risk with no postrandomization cardiovascular event (IR/100 patient-years, 0.27 [95% CI, 0.24-0.30]). Postrandomization myocardial infarction (hazard ratio [HR], 3.64 [95% CI, 2.85-4.66]) and heart failure (HR, 4.55 [95% CI, 3.33-6.22]) significantly increased future risk of sudden death. Conclusions Patients stabilized within 10 days of an ACS remain at long-term risk of sudden death with the greatest risk in those with an additional cardiovascular event. These results refine the long-term risk and risk effectors of sudden death, which may help clinicians identify opportunities to improve care. Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00202878.
与急性冠状动脉综合征（ACS）后射血分数降低的患者不同，对于 ACS 稳定患者在猝死前的心血管事件的长期发生率和影响知之甚少。
在 IMPROVE-IT（改善他汀类药物降低终点事件的国际试验）中，研究了 18144 例 ACS 后 10 天内稳定的患者。计算了猝死的累积发生率（IR）和每 100 例患者年的 IR。使用 Cox 比例风险模型，检查了随机分组后≥1 次心血管事件（心肌梗死、卒中和不稳定型心绞痛或心力衰竭住院）与猝死的关系。比较了早期（ACS 后≤1 年）和晚期（ACS 后>1 年）猝死。2446 例总死亡中，402 例（16%）为猝死。猝死的中位时间为 2.7 年，其中 109 例为早期猝死，293 例为晚期猝死。7 年随访时的累积 IR 为 2.47%（95%CI，2.23%-2.73%）。随机分组后心血管事件（402 例猝死中的 150 例[37%]；中位时间 1.4 年）后的猝死风险更大（IR/100 患者年，1.45[95%CI，1.23-1.69]），而非随机分组后无心血管事件（IR/100 患者年，0.27[95%CI，0.24-0.30]）。随机分组后的心肌梗死（HR，3.64[95%CI，2.85-4.66]）和心力衰竭（HR，4.55[95%CI，3.33-6.22]）显著增加了未来猝死的风险。
ACS 后 10 天内稳定的患者仍存在长期猝死风险，有额外心血管事件的患者风险最大。这些结果细化了猝死的长期风险和风险因素，这可能有助于临床医生确定改善治疗的机会。
