Risk-factors associated with extremely high cardiovascular risk of mid- and long-term mortality following myocardial infarction: Analysis of the Hyperlipidaemia Therapy in tERtiary Cardiological cEnTer (TERCET) registry. (September 2021) - Dyrbuś, Krzysztof
Abstract: Background and aims: Risk-factor identification and risk stratification are prerequisites to the effective primary and secondary prevention of cardiovascular disease (CVD). Patients at the highest risk benefit the most from the intensive risk-factor reduction. However, the high-risk patients' group is heterogeneous, and it is increasingly recognised that there is an 'extreme-risk' category of patients who may require particularly close attention and intensive therapeutic approach. The aim of this study was to identify subgroups of patients at the highest risk of death following myocardial infarction (MI) that might be considered as those at extremely high CVD risk. Methods: We used data from 19, 582 participants of the Hyperlipidaemia Therapy in tERtiary Cardiological cEnTer (TERCET) Registry (NCT03065543) of patients with ischaemic heart disease in Poland from 2006 to present. Characteristics of 13, 052 patients with chronic coronary syndromes (CCS) were compared with those of 4295 patients with myocardial infarction (STEMI and NSTEMI). Multivariable logistic regression with stepwise backward elimination was used to identify risk factors associated with mortality in the 12–36 months following the index hospitalisation. Results: The mortality rates were significantly higher in patients after MI than in patients with CCS. In the multivariable analysis, the risk factors most strongly associated with 12-month mortality in patients after MI were left ventricular ejection fraction (LVEF) lower than 35% (hazard ratio [HR] 3.83, 95% confidence interval [CI] 3.14–4.67), age >75 years (HR 1.91, 95%CI 1.55–2.35), multivessel coronary artery disease (HR 1.61, 95%CI 1.30–1.99), atrial fibrillation (HR 1.53, 95%CI 1.21–1.94) diabetes mellitus (HR 1.35, 95%CI 1.11–1.64) and increased LDL-C (HR per 1 mmol/l 1.09, 95%CI 1.01–1.19) or creatinine levels (HR per 10 μmol/L 1.04, 95% CI 1.04–1.05). The risk factors that influenced mortality after 24–36 months were consistent with those after 12 months, with additional low haemoglobin (20–25% risk increase per 1 mmol reduction) and chronic obstructive pulmonary disease (65% risk increase after 36 months). Conclusions: In our large, single-center real-world analysis, we identified the patients with the highest risk of death who could probably benefit the most from the most intensive therapy, and hence should be considered to be an 'extreme risk' population. Graphical abstract: Image 1 Highlights: There is still a large discussion on the most suitable definition of extremely high-risk CVD patients. To the best of our knowledge, it is the first analysis that validates the available definitions of the extremely high risk patients. LVEF<35%, age>75 years, AF, MVCAD, DM, increased LDL-C or Cr and decreased Hb levels were the RFs associated with higher mortality in MI patients. The patients with these risk factors constitute the population with the highest risk of death that should be considered the 'extreme risk' population. These patients are expected to derive the most benefit from intensive lipid-lowering combination therapy.