Short-term prognostic effect of prior cerebrovascular and peripheral artery disease in patients with acute coronary syndrome: Can we do better?

Abstract

Background:

We sought to evaluate the impact of prior cerebrovascular and/or peripheral arterial disease (PAD) on in-hospital outcomes in patients with acute coronary syndromes.

Methods:

From 1 October 2010 to 26 February 2016, 13,904 acute coronary syndrome patients were enrolled in a national multicentre registry. They were divided into four groups: prior stroke/transient ischaemic attack (stroke/TIA); prior PAD; prior stroke/TIA and PAD; none. The endpoints included in-hospital mortality and a composite endpoint of death, re-infarction and stroke during hospitalization.

Results:

6.3% patients had prior stroke/TIA, 4.2% prior PAD and 1.4% prior stroke/TIA and PAD. Prior stroke/TIA and/or PAD patients were less likely to receive evidence-based medical therapies (dual antiplatelet therapy: stroke/TIA= 88.6%, PAD= 86.6%, stroke/TIA+PAD= 85.7%, none= 92.2%, p<0.001; β-blockers: stroke/TIA= 77.1%, PAD= 72.1%, stroke/TIA+PAD= 71.9%, none= 80.8%, p<0.001; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers: stroke/TIA= 86.3%, PAD= 83.6%, stroke/TIA+PAD= 83.2%, none= 87.1%, p=0.030) and to undergo percutaneous revascularization (stroke/TIA= 52.8%, PAD= 45.6%, stroke/TIA+PAD= 43.7%, none= 67.9%, p<0.001), despite more extensive coronary artery disease (three-vessel disease: stroke/TIA= 29.1%, PAD= 38.3%, stroke/TIA+PAD= 38.3%, none= 20.2%, p<0.001). In a multivariable analysis, prior stroke/TIA+PAD was a predictor of in-hospital mortality (odds ratio= 2.828, 95% confidence interval 1.001–7.990) and prior stroke/TIA (odds ratio= 1.529, 95% confidence interval 1.056–2.211), prior PAD (odds ratio= 1.618, 95% confidence interval 1.034–2.533) and both conditions (odds ratio= 3.736, 95% confidence interval 2.002–6.974) were associated with the composite endpoint.

Conclusion:

A prior history of stroke/TIA and/or PAD was associated with lower use of medical therapy and coronary revascularization and with worst short-term prognosis. An individualized management may improve their poor prognosis.

Keywords

Acute coronary syndrome prior stroke prior transient ischaemic attack prior peripheral artery disease prognosis in-hospital management

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References

Jashari

Ibrahimi

Nicoll

. Coronary and carotid atherosclerosis: Similarities and differences. Atherosclerosis 2013; 227: 193–200.

Imori

Akasaka

Ochiai

. Co-existence of carotid artery disease, renal artery stenosis, and lower extremity peripheral arterial disease in patients with coronary artery disease. Am J Cardiol 2014; 113: 30–35.

Lee

Goodman

Yan

. Disparities in management patterns and outcomes of patients with non-ST-elevation acute coronary syndrome with and without a history of cerebrovascular disease. Am J Cardiol 2010; 105: 1083–1089.

Morillas

Quiles

Cordero

. Impact of clinical and subclinical peripheral arterial disease in mid-term prognosis of patients with acute coronary syndrome. Am J Cardiol 2009; 104: 1494–1498.

Froehlich

Mukherjee

Avezum

. Association of peripheral artery disease with treatment and outcomes in acute coronary syndromes. The Global Registry of Acute Coronary Events (GRACE). Am Heart J 2006; 151: 1123–1128.

Januzzi

Jr Buros

Cannon

. Peripheral arterial disease, acute coronary syndromes, and early invasive management: The TACTICS TIMI 18 trial. Clin Cardiol 2005; 28: 238–242.

Bertomeu

Morillas

Gonzalez-Juanatey

. Prevalence and prognostic influence of peripheral arterial disease in patients >or=40 years old admitted into hospital following an acute coronary event. Eur J Vasc Endovasc Surg 2008; 36: 189–196.

Bhatt

Peterson

Harrington

. Prior polyvascular disease: Risk factor for adverse ischaemic outcomes in acute coronary syndromes. Eur Heart J 2009; 30: 1195–1202.

Subherwal

Bhatt

. Polyvascular disease and long-term cardiovascular outcomes in older patients with non-ST-segment-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes 2012; 5: 541–549.

10.

Cotter

Cannon

McCabe

. Prior peripheral arterial disease and cerebrovascular disease are independent predictors of adverse outcome in patients with acute coronary syndromes: Are we doing enough? Results from the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis In Myocardial Infarction (OPUS-TIMI) 16 study. Am Heart J 2003; 145: 622–627.

11.

Consuegra-Sanchez

Melgarejo-Moreno

Galcera-Tomas

. Impact of previous vascular burden on in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction. Rev Esp Cardiol (Engl Ed) 2014; 67: 471–478.

12.

Mukherjee

Eagle

Kline-Rogers

. Impact of prior peripheral arterial disease and stroke on outcomes of acute coronary syndromes and effect of evidence-based therapies (from the Global Registry of Acute Coronary Events). Am J Cardiol 2007; 100: 1–6.

13.

Labinaz

Mathias

Pieper

. Outcomes of patients with acute coronary syndromes and prior percutaneous coronary intervention: A pooled analysis of three randomized clinical trials. Eur Heart J 2005; 26: 128–136.

14.

Ducrocq

Amarenco

Labreuche

. A history of stroke/transient ischemic attack indicates high risks of cardiovascular event and hemorrhagic stroke in patients with coronary artery disease. Circulation 2013; 127: 730–738.

15.

Portuguese Registry on Acute Coronary Syndromes (ProACS, 2nd phase). Registry Protocol, http://www.spc.pt/DL/Home/listdestaques/Definicoes_das_Variaveis_RNSCA_2aFase_Final.pdf (2010, acessed 5 October 2016).

16.

Rao

O’Grady

Pieper

. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol 2005; 96: 1200–1206.

17.

Subherwal

Patel

Kober

. Peripheral artery disease is a coronary heart disease risk equivalent among both men and women: results from a nationwide study. Eur J Prev Cardiol 2015; 22: 317–325.

18.

Diener

Bogousslavsky

Brass

. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): Randomised, double-blind, placebo-controlled trial. Lancet 2004; 364: 331–337.

19.

Wiviott

Braunwald

McCabe

. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007; 357: 2001–2015.

20.

James

Storey

Khurmi

. Ticagrelor versus clopidogrel in patients with acute coronary syndromes and a history of stroke or transient ischemic attack. Circulation 2012; 125: 2914–2921.