Prior polyvascular disease: Risk factor for adverse ischaemic outcomes in acute coronary syndromes

VA Boston Healthcare System and Brigham and Women's Hospital, Boston, MA, USA.
European Heart Journal (Impact Factor: 15.2). 04/2009; 30(10):1195-202. DOI: 10.1093/eurheartj/ehp099
Source: PubMed


The presence of peripheral arterial disease (PAD) or cerebrovascular disease (CVD) is associated with higher likelihood of significant coronary artery disease (CAD). We sought to assess the prevalence of PAD, CVD, prior CAD, or pre-existent disease in multiple arterial territories ('polyvascular' disease) in patients presenting with non-ST-segment elevation acute coronary syndrome and its impact on adverse events.
Data from 95 749 patients enrolled from February 2003 to September 2006 at 484 sites in the CRUSADE registry were analysed. Patients were categorized as having prior 0, 1, 2, or 3 affected arterial beds. The rates of in-hospital mortality, myocardial infarction, stroke, and congestive heart failure were analysed, as were the rates of non-bypass surgery-related red blood cell transfusion and major bleeding. On presentation, 11,345 (11.9%) patients had established PAD, 9973 (10.4%) had documented CVD, and 41,404 (43.2%) had prior CAD. In this cohort, 0, 1, 2, and 3 arterial bed disease before presentation was present in 46 814 (48.9%, 95% CI 48.6-49.2%), 36 704 (38.3%, 95% CI 37.8-39.0%), 10 675 (11.2%, 95% CI 10.9-11.9%), and 1556 (1.6%, 95% CI 1.5-1.8%) patients, respectively. The rates of ischaemic events increased with the number of affected vascular beds. The adjusted odds ratio for the composite of in-hospital ischaemic events for pre-existent disease in 1, 2, or 3 arterial beds (compared with 0 arterial bed involvement) increased from 1.07 to 1.26 to 1.31 (P < 0.001). Similarly, the adjusted odds ratio for transfusion increased with greater disease burden from 1.11 to 1.28 to 1.30 (P < 0.001), although the adjusted rates of protocol-defined non-bypass surgery-related major bleeding did not.
Prior polyvascular disease increases the risk of in-hospital adverse events, including mortality. Identification of these patients in clinical trial and real world populations may provide an opportunity to reduce their excess risk with intensive secondary prevention efforts.

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    • "There has also been growing interest in the use of remote ischaemic preconditioning as an intervention in experimental studies7 and randomized trials to improve outcomes after coronary interventions.8–10 However, there is also evidence that patients with prior atherosclerotic disease diagnoses in one or more arterial territory are likely to have more advanced atherosclerotic disease and therefore poorer outcomes.11 The effect of myocardial or remote ischaemia at different times prior to a first AMI on subsequent coronary mortality is unclear, especially in the longer term (Supplementary material online, Table S1).3,12–14 "
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    ABSTRACT: Background Ischaemia in different arterial territories before acute myocardial infarction (AMI) may influence post-AMI outcomes. No studies have evaluated prospectively collected information on ischaemia and its effect on short- and long-term coronary mortality. The objective of this study was to compare patients with and without prospectively measured ischaemic presentations before AMI in terms of infarct characteristics and coronary mortality. Methods and results As part of the CALIBER programme, we linked data from primary care, hospital admissions, the national acute coronary syndrome registry and cause-specific mortality to identify patients with first AMI (n = 16,439). We analysed time from AMI to coronary mortality (n = 5283 deaths) using Cox regression (median 2.6 years follow-up), comparing patients with and without recent ischaemic presentations. Patients with ischaemic presentations in the 90 days before AMI experienced lower coronary mortality in the first 7 days after AMI compared with those with no prior ischaemic presentations, after adjusting for age, sex, smoking, diabetes, blood pressure and cardiovascular medications [HR: 0.64 (95% CI: 0.57–0.73) P < 0.001], but subsequent mortality was higher [HR: 1.42 (1.13–1.77) P = 0.001]. Patients with ischaemic presentations closer in time to AMI had the lowest seven day mortality (P-trend = 0.001). Conclusion In the first large prospective study of ischaemic presentations prior to AMI, we have shown that those occurring closest to AMI are associated with lower short-term coronary mortality following AMI, which could represent a natural ischaemic preconditioning effect, observed in a clinical setting. Clinical trials registration identifier NCT01604486.
    Full-text · Article · Jul 2014 · European Heart Journal
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    • "PAD has a variable yet relatively high prevalence in the western world. 8–11 Patients with PAD are at increased risk of coronary, carotid and cerebrovascular atherosclerosis disease and all-cause mortality. 12–15 These predictors are independent of the traditional risk factors of PAD. 15–17 PAD is not a static disease and its progression from intermittent claudication to rest pain or gangrene can occur. 14–17 The prevalence of PAD in the general population depends on the definition used and is substantially underestimated, if one considers onl"
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    ABSTRACT: Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis and is associated with significant morbidity and mortality. The prevalence of PAD in the developed world is approximately 12% among adult population, which is age-dependent and with men being affected slightly more than women. Despite the strikingly high prevalence of PAD, the disease is underdiagnosed. Surprisingly, more than 70% of primary health care providers in the US were unaware of the presence of PAD in their patients. The clinical presentation of PAD may vary from asymptomatic to intermittent claudication, atypical leg pain, rest pain, ischemic ulcers, or gangrene. Claudication is the typical symptomatic expression of PAD. However, the disease may remains asymptomatic in up to 50% of all PAD patients. PAD has also been reported as a marker of poor outcome among patients with coronary artery disease. Despite the fact that the prevalence of atherosclerotic disease is increasing in the Middle East with increasing cardiovascular risk factors (tobacco use, diabetes mellitus and the metabolic syndrome), data regarding PAD incidence in the Middle East are scarce.
    Full-text · Article · Jul 2013
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    • "Most other studies, performed in younger age groups, have evaluated risks after an event in a specific cardiovascular bed (cardiac, cerebral, or peripheral) (Migliaccio-Walle et al. 2010; Bhatt et al. 2009; Arima et al. 2006; Touze et al. 2005) or observed differences in risk between one or multiple CVD sites (Ferrieres et al. 2006; Migliaccio-Walle et al. 2010; Bhatt et al. 2009; Steg et al. 2007). The high risk of recurrent stroke in the group with a history of TIA or stroke that we observed is in line with previous studies (Steg et al. 2007; Arima et al. 2006; Ferrieres et al. 2006; Vickrey et al. 2002). "
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    ABSTRACT: This study aimed to explore the prognosis of very old people depending on their cardiovascular disease (CVD) history. This observational prospective cohort study included 570 participants aged 85 years from the general population with 5-year follow-up for morbidity, functional status, and mortality. At baseline, participants were assigned to three groups: no CVD history, "minor" CVD (angina pectoris, transient ischemic attack, intermittent claudication, and/or heart failure), or "major" CVD (myocardial infarction [MI], stroke, and/or arterial surgery). Follow-up data were collected on MI, stroke, functional status, and cause-specific mortality. The composite endpoint included cardiovascular events (MI or stroke) and cardiovascular mortality. At baseline, 270 (47.4 %) participants had no CVD history, 128 (22.4 %) had minor CVD, and 172 (30.2 %) had major CVD. Compared to the no CVD history group, the risk of the composite endpoint increased from 1.6 (95 % confidence interval [CI], 1.1-2.4) for the minor CVD group to 2.7 (95 % CI, 2.0-3.9) for the major CVD group. Similar trends were observed for cardiovascular and all-cause mortality risks. In a direct comparison, the major CVD group had a nearly doubled risk of the composite endpoint (hazard ratio, 1.8; 95 % CI, 1.2-2.7), compared to the minor CVD group. Both minor and major CVD were associated with an accelerated decline in cognitive function and accelerated increase of disability score (all p < 0.05), albeit most pronounced in participants with major CVD. CVD disease status in very old age is still of important prognostic value: a history of major CVD (mainly MI or stroke) leads to a nearly doubled risk of poor outcome, including cardiovascular events, functional decline, and mortality, compared with a history of minor CVD.
    Full-text · Article · Jul 2012 · Age
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