Survivors of MI Not Out of Danger After 1 Year

The risk of cardiovascular events after acute MI remains relatively high in patients who survive the first postdischarge year without any difficulties, according to a study published online January 13, 2015, ahead of print in the European Heart Journal. 

Thus, “MI patients should be carefully monitored and managed with effective prevention programs beyond the first year, particularly in those considered to be at high-risk of subsequent ischemic events,” write Tomas Jernberg, MD, PhD, of Karolinska University Hospital (Stockholm, Sweden), and colleagues.

LeRoy E. Rabbani, MD, of Columbia University Medical Center (New York, NY), called the study “sobering” in a telephone interview with TCTMD. Cardiologists and patients should not relax after the first post-MI year, he advised, adding that patients should enter cardiac rehab programs to make the needed lifestyle changes associated with improved outcomes.

Dr. Jernberg’s team examined Swedish national registry data on patients admitted with a primary diagnosis of acute MI from July 2006 through June 2011. The analysis included 97,254 patients (mean age 72.4 years; 62% male) who survived for at least a week after discharge. Fewer than half of patients (48.1%) received invasive treatment within 30 days of admission.

In the first year, the combined rate of MI, stroke, or cardiovascular death (primary endpoint) was 18.3%. More than half of the events (55.5%) were recurrent MI, 31% were cardiovascular death, and 13.4% were stroke. Another 4.2% of patients died from noncardiovascular causes.

The researchers identified several independent predictors of the primary endpoint for the first year after multivariate adjustment (table 1).

 

Patients who were still alive and free from recurrent MI or stroke at 1 year were younger, had less comorbidity, and were more likely to undergo invasive treatment for the index MI compared with the overall initial patient population. In these stable MI patients, the rate of composite events starting at the end of the first year was 20.0% over the next 3 years. Of those events, 40.8% were recurrent MI, 40.6% were cardiovascular death, and 18.6% were stroke. Another 5.9% of patients died of noncardiovascular causes.

Predictors of the primary endpoint from 1 to 4 years were the same as those for the first year, except for prior unstable angina, which was no longer significantly related.

Prolonged Attention Warranted

Because of falling MI rates and improving survival 1 year after MI in recent years, the stable post-MI patient population—those living at least a year after discharge without recurrent events—is growing, Dr. Jernberg and colleagues note.

“Compared with other chronic disease patient populations where regular follow-up in specialist care is often combined with follow-up primary care, the involvement of specialist care was less structured and less frequent for the stable post-MI patients,” they write.

Pointing to the residual cardiovascular risk beyond 1 year and the complex treatment regimens used for other conditions, they argue that “prolonged effective prevention programs and sustained contact with a cardiologist, parallel to contact with a general practitioner, may be warranted in this population.”

John P. Erwin III, MD, of Baylor Scott & White Health (Temple, TX), agrees. “These days, many people—especially in the United States—survive their myocardial infarction after having a minimally invasive procedure… and don't really believe that what they've just experienced was a big deal,” he told TCTMD in an email. “A comprehensive approach to lifestyle modification and secondary prevention with good pharmacological agents has been shown to reduce recurrent events and lower death rates.”

He pointed out that although referral for cardiac rehabilitation programs—which have been shown to improve outcomes—is common, few patients participate long term. That phenomenon also was observed in the Swedish study.

“Potentially there [has] been some complacency [after the first year] because we do have excellent medicines that we treat people with and we have all these technologies we use,” Dr. Rabbani said. “But at the end of the day, it’s still sobering, and it just points to the fact that really it’s a combination of lifestyle changes, as well as the medications, that keep people healthy post-MI.”

 

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Source:
Jernberg T, Hasvold P, Henriksson M, et al. Cardiovascular risk in post-myocardial infarction patients: nationwide real world data demonstrate the importance of a long-term perspective. Eur Heart J. 2015;Epub ahead of print.

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