High Rate of Clinical Events at 6 Months for Ischemic CVD Patients

Nearly one-quarter of patients across a broad spectrum of ischemic cardiovascular conditions, including those undergoing PCI, are rehospitalized or dead within 6 months, according to the results of a new observational study.

Of the 2,420 patients from 10 countries in the European Society of Cardiology’s Chronic Ischemic Cardiovascular Disease (CICD) pilot study, 2.6% had died at 6 months, mostly from cardiovascular causes. The overall rate of rehospitalization was 22.5%, with the vast majority of patients rehospitalized for cardiovascular reasons.

The researchers, led by Michel Komajda, MD (Hospital Saint Joseph, Paris, France), say the overall clinical event rate is quite high, although in line with other observational studies, and confirms that individuals with chronic ischemic disease are at high cardiovascular risk and should be carefully followed. In an email, Komajda told TCTMD that while it is known NSTEMI patients are at high risk for future cardiovascular events, less is known about patients with stable CAD or peripheral artery disease.

“It emphasizes the need for aggressive secondary prevention measures in this population,” he said.

To TCTMD, Howard Weintraub, MD (NYU Langone Medical Center, New York, NY), said the treatment of patients with chronic ischemic cardiovascular disease depends on the presentation. For patients with acute coronary syndromes, physicians would consider an invasive evaluation and potential PCI. For other patients, such as those with chronic stable CAD, there is a larger opportunity for different approaches.

“I personally believe that a noninvasive evaluation should be done,” said Weintraub. “Depending upon the degree of ischemia, decisions can be made. The results from the ongoing ISCHEMIA trial may be very helpful in this regard. In cases of chronic ischemic heart disease there is great importance in addressing risk factors, which would include changes in lifestyle [with diet and exercise], as well as medications to minimize the impact of hyperlipidemia, hypertension, diabetes, and continued smoking.”

The study was published online January 16, 2018, in the European Journal of Preventive Cardiology.

The CICD Pilot Study

The CICD pilot registry is intended to characterize patients with chronic ischemic cardiovascular disease, including peripheral artery disease, in terms of demographics, clinical profiles, and outcomes. Patients were recruited from 100 clinical centers in France, Germany, Latvia, Lithuania, Poland, Romania, Russia, Greece, Italy, and Portugal.

Patients included in the study were those with chronic CAD and NSTEMI undergoing PCI within 72 hours of symptom onset (cohort 1), patients with stable CAD undergoing elective PCI (cohort 2), stable CAD patients treated at general hospitals and clinics without interventional/surgical facilities (cohort 3), and patients with peripheral artery disease (cohort 4).

The combined endpoint of death/rehospitalization at 6 months occurred in 23.7% of patients overall. Looking only at cardiovascular-related deaths and hospitalizations, the rate was 19.5%. In cohorts 1, 2, 3, and 4, the rate of all-cause mortality/all-rehospitalization at 6 months was 28.0%, 19.9%, 22.9%, and 29.6%, respectively. For cardiovascular deaths and rehospitalizations specifically, the rates were 23.7%, 16.0%, 19.1%, and 22.2% in the respective cohorts.

Independent predictors of death and rehospitalization included older age, a history of previous peripheral revascularization, chronic kidney disease, and presenting with NSTEMI (cohort 1).

Jeffrey Anderson, MD (Intermountain Medical Center Heart Institute, Salt Lake City, UT), who was not involved in the study, pointed out that while the rate of hospitalization at 6 months seems high, most of the readmissions were unrelated to CAD. In fact, the rate of CAD-related hospitalizations was 10.7%. At 2.0%, the rate of cardiovascular-related death “seems reasonable” and in line with their clinical experience, he added.

To TCTMD, Anderson said the 2014 American College of Cardiology/American Heart Association guidelines for the treatment of stable ischemic heart disease identify two aims for therapy: treating symptoms and lowering the risk of mortality. To reduce symptoms, beta-blockers, calcium-channel blockers, nitroglycerine, and ranolazine are options, as is PCI in selective cases. For long-term treatment, statins, beta-blockers, ACE inhibitors, aspirin, antiplatelet therapy, and the selective use of PCI or CABG are utilized to lower the risk of death, he said.      

Weintraub said age is always associated with greater risk, while prior revascularization potentially identifies more long-standing, previously unstable, cardiovascular disease. The present analysis, however, does not stratify patients based on baseline therapy or by who attained optimal targets of systolic blood pressure, LDL cholesterol, and other risk factors, he said. Anderson noted that while it might be expected that revascularized patients would be at lower risk, there is selection bias at play and these patients might simply be at higher risk.

The researchers point out that the baseline use of medical therapy was similar to or higher than seen in other contemporary registries, particularly the use of renin-angiotensin system inhibitors, beta-blockers, and aspirin. By 6 months, though, there was a decrease in the use of these drugs. “There is a general trend for a mild reduction in the prescription of secondary preventive therapies in this very high cardiovascular risk population,” write Komajda and colleagues.