Background: Microalbuminuria is associated with adverse outcomes in acute coronary syndrome (ACS) patients.Methods: To evaluate the very long-term association between Microalbuminuria and the overall mortality and causes of death in this clinical setting, we prospectively studied 579 unselected ACS patients admitted to three hospitals. The baseline albumin-to-creatinine ratio (ACR) was measured on days 1, 3, and 7 in 24-h urine samples. Patients were followed for 22 years or until death.Results: Virtually all patients completed follow-up; 449(78%) had died: 41% due to non-sudden cardiac death (non-SCD), 19% sudden cardiac death (SCD), 40% due to non-cardiac (non-CD) death. Using unadjusted Cox regression analysis, ACR was a significant predictor of all-cause mortality (hazard ratio [HR] 1.26;95%confidence interval [CI] 1.22–1.31; p˂0.0001) and the three causes of death (HR 1.40;95%CI 1.32–1.48; p˂0.0001), (HR 1.22;95%CI 1.12–1.32; p˂0.0001) and (HR 1.16;95%CI 1.09–1.23; p˂0.0001) for non-SCD, SCD and non-CD respectively.Using a fully adjusted model, ACR was a significant independent predictor of all-cause mortality(HR 1.12; 95% CI 1.08–1.16; p˂0.0001) and only non-SCD (HR 1.21; 95%CI 1.14–1.29; p˂0.0001). There was a positive interaction between ACR level and history of AMI (HR 1.15; 95%CI 1.03– 1.29; p = 0.01) and the presence of heart failure at admission (HR 1.11; 95%CI 1.01–1.24; p =0.04), and negative interaction with higher than median LVEF (HR 0.89; 95%CI 0.80–0.99; p =0.03) for all-cause mortality at the multivariable level.Conclusion: Based on the present analysis, baseline urinary albumin excretion during ACS is a strong independent predictor of the very long-term mortality risk, chiefly due to non-sudden cardiac death.
Background: An increased risk of cancer death has been demonstrated for patientsdiagnosed with acute coronary syndrome (ACS). We are investigating possiblegeographic risk disparities.Methods: This prospective study included 541 ACS patients who were admitted tohospitals and discharged alive in three provinces of Italy’s Veneto region. The patientswere classified as residing in urban or rural areas in each province.Results: With 3 exceptions, all patients completed the 22-year follow-up or were followeduntil death. Urban (46%) and rural (54%) residents shared most of their baselinedemographic and clinical characteristics. Pre-existing malignancy was noted in 15patients, whereas 106 patients developed cancer during the follow-up period, whichrepresented 6232 person-years. No difference in the cancer death risk was foundbetween the urban and rural areas or between southern and northern provinces(hazard ratio [HR] 1.1; 95% confidence interval [CI] 0.7–1.7; p = 0.59 and HR 1.1; 95%CI 0.9–1.4; p = 0.29, respectively) according to the unadjusted Cox regression analysis.Geographic areas, however, showed a strong positive interaction, with risk increasingfrom the urban to rural areas from southern to northern provinces (HR 1.9; 95% CI 1.1–3.0; p = 0.01). The fully adjusted Cox regression and Fine-Gray competing risk regressionmodels provided similar results. Interestingly, these results persisted, and evenstrengthened, after exclusion of the 22 patients who developed malignancy andsurvived to the end of follow-up. We did not observe an urban/rural difference in nonneoplasticdeath risk or a significant interaction between the geographic areas.Conclusion: Our analysis reveals that the cancer death risk among unselected ACSpatients in Italy’s Veneto region significantly differs by geography. The northern rural areahas the highest risk. These results highlight the importance of implementing a preventivepolicy based on area-specific knowledge.
G. Berton, R. Cordiano, F. Cucchini, F. Cavuto, M. Pellegrinet, P. PalatiniAims: Atrial fibrillation⁄flutter (AF⁄FL) is a common complication of acute myocar-dial infarction (AMI). Indeed, the determinants of AF⁄FL in AMI-patients and theassociation of AF⁄FL with mortality are not well-known. The purpose of the pres-ent study was to investigate the relationship between presence of AF⁄FL and mor-tality in patients with AMI and to report on predictors of AF⁄FL.Methods: We studied 505 patients enrolled in three intensive care units with definite AMI andfollowed up for 7 years. No patient was lost to follow-up. Patients with AF⁄FLduring the 1st week of hospitalisation were compared with those with steady sinusrhythm. End-points were all-cause mortality and modes of death.Results: At multivariable logistic regression analysis, elderly, body mass index, congestive heartfailure (CHF), history of hypertension and plasma cholesterol (in a negative fashion)were independently associated with the presence of AF⁄FL. At survival analysis,after full adjustment, AF⁄FL was not associated with in-hospital mortality. After7 years of follow-up, AF⁄FL was found to be associated with all-cause mortality[adjusted odds ratio (OR) = 1.6; 95% confidence interval (CI) = 1.2–2.3], togetherwith age, diabetes mellitus, creatine kinase-MB isoenzyme (CK-MB) peak, CHF,estimated glomerular filtration rate and thrombolysis. At adjusted logistic polyno-mial regression analysis, AF⁄FL was found to be associated with an excess of mor-tality for reasons of sudden death (SD) (adjusted OR = 2.7; 95% CI = 1.2–6.4).No interaction was observed between AF⁄FL and medications on in-hospitalmortality. For 7-year mortality, angiotensin-converting enzyme (ACE)-inhibitors anddigitalis showed an independent negative (protective) interaction chiefly on SD(adjusted OR = 0.06; 95% CI = 0.01–0.74, and RR = 0.10; 95% CI = 0.02–0.58, respectively).Conclusions: Patients with AMI and AF⁄FL portend a poorprognosis in the long-term chiefly because of an excess of SD. Treatment withACE-inhibitors and digitalis may have long-term beneficial effects on SD.
Giuseppe Berton, Rosa Palmieri, Rocco Cordiano, Fiorella Cavuto, Sigismondo Pianca and Paolo PalatiniBackground The relationship between acute-phase inflammatory markers in the setting of acute myocardial infarction (AMI) and long-term outcomes is largely unexplored.Objectives The aim of the study was to investigate the predictive power of acute-phase inflammatory markers following AMI for short-term and long-term mortality separately and modes of death.Methods In 220 unselected patients with AMI [median age 67 (interquartile range 60-74) years, women 26%], blood neutrophil granulocytes, erythrocyte sedimentation rate, C-reactive protein, and a1-acid glycoprotein were measured 1, 3 and 7 days after admission. All patients completed 7 years of follow-up. Endpoints were 1-year (short-term) and 2- to 7-vear (long-term) mortality and modes of death, classified as nonsudden cardiovascular, sudden, and noncardiovascular death.Results The short-term mortality rate was 18%. The long- term mortality rate was 26%. The short-term mortality risk was higher in patients in whom the markers were in the upper tertile. Fully adjusted hazard ratios (and 95% confidence interval) were 3.2 (1.4-7.9), 3.5 (1.7-7.9), 3.5 (1.6-8.6), and 6.1 (2.3-19.1) for neutrophil granulocyte, erythrocyte sedimentation rate, C-reactive protein, and «i-acid glycoprotein, respectively. The excess mortality was chiefly due to nonsudden cardiovascular mortalityConclusion The acute-phase inflammatory markers tested following AMI are independently and concordantly associated with short-term mortality and their prediction is associated only with nonsudden cardiovascular modes of death. These markers are not associated with long-term mortality.Keywords C-reactive protein, inflammatory markers, long-term mortality, myocardial infarction, prognosis, short-term mortality
Giuseppe Berton, MD,FESC;Rocco Cordiano, MD;Rosa Palmieri, MD;Fiorella Cavuto, MD;Patrizio Buttazzi, PhD; Paolo Palatini, MDBackground: C-reactive protein (CRP) is an established prognostic marker in the setting of acute coronarysyndromes. Recently, albumin excretion rate also has been found to be associated with adverse outcomesin this clinical setting. Our aim was to compare the prognostic power of CRP and albumin excretion rate forlong-term mortality following acute myocardial infarction (AMI).Hypothesis: To determine whether albumin excretion rate is a better predictor of long-term outcome than CRPin post-AMI patients.Methods:We prospectively studied 220 unselected patients with definite AMI (median [interquartile] age67 [60–74] y, female 26%, heart failure 39%). CRP and albumin-to-creatinine ratio (ACR) were measured onday 1, day 3, and day 7 after admission in 24-hour urine samples. Follow-up duration was 10 years for allpatients.Results: At survival analysis, both CRP and ACR were associated with increased risk of 10-year all-causemortality, also after adjusting for age, hypertension, diabetes mellitus, prehospital time delay, creatinekinase-MB isoenzyme peak, heart failure, and creatinine clearance. CRP and ACR were associated withnonsudden cardiovascular(non-SCV) mortality but not with sudden death (SD) or noncardiovascular(non-CV)death. CRP was not associated with long-term mortality, while ACR was independently associated withoutcome both in short- and long-term analyses. At C-statistic analysis, CRP did not improve the baselineprediction model for all-cause mortality, while it did for short-term non-SCV mortality. ACR improved all-causeand non-SCV mortality prediction, both in the short and long term.Conclusions: ACR was a better predictor of long-term mortality after AMI than CRP.
To the Editor. In the recently published study by Lazzeri et al. , microalbuminuria and other clinical variables were evaluated in hypertensive, nondiabetic patients with ST elevation myocardial infarction . "The authors concluded that microalbuminuria does not yield prognostic information about the inhospital mortality or complications and claimed an association between acute glucose dysmetabolism and outcomes. We believe that, in this study, the predictive power of microalbuminuria has been overlooked by the authors due to a series of methodological problems.
AbstractThe long-term event-free survival (EFS) after acute myocardial infarction (AMI) is largelyuninvestigated. We analyzed noninvasive clinical variables in association with long-termEFS after AMI. The present prospective study included 504 consecutive patients with AMIat 3 hospitals from 1995 to 1998 (Adria, Bassano, Conegliano, and Padova Hospitals [ABC]study).Thirty-seven variables were examined, including demographics, cardiovascular riskfactors, in-hospital characteristics, and blood components. The end point was 10-year EFS.Logistic and Cox regression models were used to identify the predictive factors. Wecompared 3 predictive models according to the goodness of fit and C-statistic analyses. Atenrollment, the median age was 67 years (interquartile range 58 to 75), 29% were women,38% had Killip class>1, and the median left ventricular ejection fraction was 51%(interquartile range 43% to 60%).The 10-year EFS rate was 19%. Both logistic and Coxanalyses identified independent predictors, including young age (hazard ratio 1.2, 95%confidence interval 1.1 to 1.3, p=0.0006), no history of angina (hazard ratio 1.4, 95%confidence interval 1.1 to 1.8, p=0.009), no previous myocardial infarction (hazard ratio1.4, 95% confidence interval 1.1 to 1.7, p0.01), high estimated glomerular filtration rate(hazard ratio 0.8, 95% confidence interval 0.7 to 0.9, p=0.001), low albumin/creatinineexcretion ratio (hazard ratio 1.2, 95% confidence interval 1.1 to 1.3, p<0.0001), andhighleft ventricular ejection fraction (hazard ratio 0.8, 95% confidence interval 0.7 to 0.9, p=0.006).These variables had greater predictive power and improved the predictive power of 2 othermodels, including Framingham cardiovascular risk factors and the recognized predictors ofacute heart damage. In conclusion, 10-year EFS was strongly associated with 4 factors (ABCmodel) typically neglected in studies of AMI survival, including estimated glomerular filtrationrate, albumin/creatinine excretion ratio, a history of angina, and previous myocardial infarc-tion. This model had greater predictive power and improved the power of 2 other models usingtraditional cardiovascular risk factors and indicators of heart damage during AMI.
Traduzione dall’originale: Rosanna Sedran, RN, Giuseppe Berton, MD.Predittori clinici della sopravvivenza libera da eventi per 10 anni dopo infarto miocardico acuto (da: “the Adria, Bassano, Conegliano, and Padova Hospitals [ABC] Study on Myocardial Infarction")RiassuntoLa sopravvivenza a lungo termine libera da eventi (EFS) dopo infarto miocardico acuto (AMI) è poco conosciuta.Abbiamo analizzato variabili cliniche non invasive in associazione con EFS per un lungo periodo dopo un infarto miocardico acuto. Questo studio prospettico ha riguardato 504 pazienti con infarto miocardico acuto, non selezionati, arruolati consecutivamente in 3 ospedali generali dal 1995 al 1998 (the ABC study). Trentasette variabili cliniche sono state esaminate, compresi fattori demografici, fattori di rischio cardiovascolare, caratteristiche ospedaliere e componenti ematochimici.L’obbiettivo dello studio è stato verificare l'EFS per 10 anni dopo l’AMI. Per l’analisi statistica sono stati usati modelli di regressione logistica e di Cox per identificare i fattori associati con EFS. Abbiamo confrontato 3 modelli predittivi usando analisi basate su “goodness of fit” e “C-‐ statistic”. All'inizio dello studio l'età mediana dei pazienti era di 67 anni (interquartili 58-‐75), il 29% donne, il 38% in classe di Killip > 1, e la mediana della frazione di eiezione ventricolare sinistra è stata del 51% (interquartili 43-‐60%). L’EFS a 10 anni è stato del 19%. All’analisi logistica e diCox sono stati identificati i seguenti fattori predittivi indipendenti: giovane età (hazard ratio 1,2, intervallo di confidenza 95%, 1.1-‐1.3, p=0,0006), non-‐storia di angina (hazard ratio 1,4, 95% intervallo di confidenza 1,1-‐1,8, p = 0,009), non-‐precedente infarto miocardico (hazard ratio 1,4, intervallo di confidenza 95% 1,1-‐1,7, p = 0,01), elevata velocità di filtrazione glomerulare stimata (hazard ratio 0.8, intervallo di confidenza 95% 0,7-‐0,9, p = 0.001), basso livello di escrezione di albumina/creatinina (hazard ratio 1.2, intervallo di confidenza 95% 1,1-‐1,3, p <0,0001) ed elevata frazione di eiezione ventricolare sinistra (hazard ratio 0.8, intervallo di confidenza 95% 0,7-‐0,9, p = 0.006). Queste variabili hanno mostrato maggiore potere predittivo di altri 2 modelli, che includono fattori di rischio cardiovascolare di Framingham e predittori di danno cardiaco acuto. In conclusione l'EFS per 10 anni dopo AMI è risultato fortemente associato a 4 fattori (the ABC model) sinora poco considerati negli studi di sopravvivenza dopo AMI, tra cui filtrazione glomerulare stimata, rapporto albumina/creatinina, storia di angina e precedente infarto miocardico. Questo modello ha maggiore capacità predittiva e risulta migliorativo rispetto ad altri due modelli tradizionali basati sui fattori di rischio cardiovascolare ed indicatori di danno cardiaco durante AMI.
Background: The aim of this study was to examine the prognostic value of several clinical characteristics on long-term mortality and causes of death after acute coronary syndrome.Methods: The ABC-2 study is a prospective investigation comprising 557 patients with acute coronary syndrome. During hospitalization, 33 clinical variables, including demographics, cardiovascular risk factors, in-hospital characteristics, and blood components, were examined. “Acute models” were survival models containing the variables accrued within 72 h from admission, and “sub-acute models” contained data accrued over a 7-day period. Cox regression models were used for the survival analysis.Results: The 12-year follow-up study revealed that 51.2% of the patients died (15.8% of the patients died from coronary artery disease and/or heart failure, 12.6% of the patients experienced sudden death, 8.3% of the patients died from other-cardiovascular diseases, and 14.5% of the patients died from non-cardiovascular causes. The following factors were independently associated with all-cause mortality in both the acute and sub-acute models: age, left ventricular ejection fraction (negative), body mass index (non-linear), previous myocardial infarction, diabetes mellitus, blood glucose (non-linear), Killip class>1, albumin/creatinine ratio, and pre-hospital time delay. The variables associated with coronary artery disease and/or heart failure included age, left ventricular ejection fraction (negative), body mass index (non-linear), previous myocardial infarction, Killip class>1, albumin/creatinine ratio, and pre-hospital time delay, while the variables associated with sudden death included age, hypertension (negative), uric acid, left ventricular ejection fraction (negative), and pre-hospital time delay, and those associated with other- cardiovascular causes included age, hypertension, and albumin/creatinine ratio. The only variable associated with non- cardiovascular mortality was age. The C-statistic of the predictive models was 0.86 for all-cause mortality, whereas the C-statistic ranged from 0.74 to 0.80 for cardiovascular causes.Conclusions: The ABC-2 study revealed clinical predictors of long-term mortality after acute coronary syndrome that might help prognostication, patient education, and risk modification. Furthermore, the results showed that the modes of death are independently associated with different baseline clinical features.Keywords: Acute coronary syndrome; Mortality; Risk prediction; Survival analysis
Aims: We investigated the gender-based differences in the association between heart failure (HF) during acutecoronary syndrome (ACS) and post-discharge, long-term cardiovascular (CV) mortality.Methods and results: The present study included 557 patients enrolled in three intensive coronary care units anddischarged alive. HF during ACS was evaluated by Killip class and left ventricular ejection fraction (LVEF). Inter-action between gender and HF after 15 years of follow up was studied using Cox models including a formal inter-action term. Median age was 67 (interquartile range [IQR], 59–75) years, 29% were females, 37% had non-STelevation myocardial infarction and 32% Killip classN1, and median LVEF was 53% (IQR 46–61). All butfive pa-tients were followed up to 15 years, representing 5332 person-years. Of these, 40.2% died of CV-related causes.Crude CV mortality rate was higher among women (52.2%) than men (35.3%;Pb0.0001). At a univariablelevel, a negative interaction between female gender and Killip class for CV mortality was found [hazard ratio(HR) = 0.51 (0.34–0.77),P=0.002].Infive multivariable models after controlling for age, main CV risk factors,clinical features, post-discharge medical treatment, and mechanical coronary reperfusion, the interaction wassignificant across all models [HR = 0.63 (0.42–0.95),P= 0.02 in the fully adjusted model]. LVEF showed no sig-nificant hazard associated with female gender on univariable analysis [HR = 1.4 (0.9–0.2.0),P= 0.11] but did soin all adjusted models [HR = 1.7 (1.2–2.5),P= 0.005 in the fully adjusted model].Conclusion: Gender is a consistent, independent effect modifier in the association between HF and long-term CVmortality after ACS.Keywords: Gender, Heart failure, Killip class, LVEF, Acute coronary syndrome, Cardiovascular mortality, Surviving analysis
Background: Increased cancer risk has been reported in patients with acute coronary syndrome (ACS).Objectives: To investigate geographic differences in risk malignancy long after ACS.Methods: We enrolled 586 ACS patients admitted to hospitals in three provinces in the Veneto region of Italy in this prospective study. Patient’s residency was classified into three urban and three nearby rural areas.Results: All (except for 3) patients completed the follow-up (22 years or death) and 54 % were living in rural areas. Sixteen patients had pre-existing malignancy, and 106 developed the disease during follow-up. Cancer prevalence was 17 % and 24 % (p = 0.05) and incidence of malignancy was 16 and 21/1000 person-years for urban and rural areas, respectively. In unadjusted logistic regression analysis, cancer risk increased from urban to rural areas (odds ratio [OR] 3.4;95 % confidence interval [CI] 1.7–7.1; p = 0.001), with little change from north to south provinces (OR 1.5;95 % CI 1.0-2.2; p = 0.06). Yet, we found a strong positive interaction between urban-rural areas and provinces (OR 2.1;95 % CI 1.2–3.5; p = 0.003). These results kept true in the fully adjusted model. Unadjusted Cox regression analysis revealed increasing hazards ratios (HRs) for malignancy onset from urban to rural areas (HR 3.0;95 % CI 1.5–6.2; p = 0.02), but not among provinces (HR 1.3;95 % CI 1.0–2.0; p = 0.14). Also, we found a strong positive interaction between geographic areas (HR 2.1;95 % CI 1.3–3.5; p = 0.002), even with a fully adjusted model.Conclusions: The results in unselected real-world patients demonstrate a significant geographic difference in malignancy risk in ACS patients, with the highest risk in the north-rural area.Keywords: Acute coronary syndrome, Malignancy risk, Urban-Rural.