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Canadian Journal of Cardiology

Determinants of Early and Late In-Hospital Mortality After Acute Myocardial Infarction: A Subanalysis of the OBTAIN Registry

Published:October 20, 2022DOI:https://doi.org/10.1016/j.cjca.2022.10.019

      Abstract

      Background

      Predictors of in-hospital mortality after myocardial infarction (MI) have been reported dichotomously: survival vs death. Predictors of time from admission to death have not been reported.

      Methods

      A total of 7335 patients were enrolled in a prospective multicentre registry of acute MI. In-hospital mortality was classified by time from admission as acute (≤ 2 days), subacute (3 to 7 days), late (8 to 14 days), and very late (≥ 15 days) to identify factors associated with time to death in patients who died before discharge. Patient and MI characteristics, in-hospital interventions, and electrocardiographic findings were screened for differences in time to in-hospital death.

      Results

      In-hospital death affected 351 patients (4.8%). Mean age was 72.0 ± 12.4 years, and 40.5% were female patients. Median survival was 5 days (interquartile range: 2-12), and 41% of in-hospital deaths occurred after 1 week. Cardiac biomarkers and ejection fraction were not related to time to in-hospital death. Previous MI, systolic blood pressure, pharmacologic therapy, and interventional treatments were different among the 4 groups. The factors associated with late in-hospital death were coronary artery bypass graft surgery (CABG), new-onset atrial fibrillation or flutter, heart failure or pulmonary edema, bleeding, and lung disease. Acute and subacute in-hospital death was associated with ST-elevation MI, lower systolic blood pressure, and cardiac arrest on admission. CABG was performed in 12% of post-MI patients who died in hospital.

      Conclusions

      Clinical risk factors for in-hospital mortality evolve over time immediately after acute MI. Understanding the time-dependent risk factors may allow for the development of new approaches to curtail the “later” in-hospital mortality.

      Résumé

      Contexte

      Les facteurs prédictifs de mortalité hospitalière après un infarctus du myocarde (IM) sont présentés en fonction de la dichotomie survie/décès. Les facteurs prédictifs du temps écoulé entre l’admission à l’hôpital et le décès des patients sont omis.

      Méthodologie

      Au total, 7335 patients ont été inscrits dans un registre prospectif multicentrique de cas d’IM aigu. La mortalité hospitalière, ventilée en fonction du temps écoulé depuis l’admission à l’hôpital, pouvait être aiguë (décès après 2 jours ou moins), subaiguë (décès après de 3 à 7 jours), tardive (décès après de 8 à 14 jours) ou très tardive (décès après 15 jours ou plus). Cette ventilation visait à cerner les facteurs associés au temps écoulé avant les décès hospitaliers. Les caractéristiques individuelles et celles de l’IM, les interventions intrahospitalières et les résultats électrocardiographiques ont fait l’objet d’un examen visant à déceler des différences au chapitre du temps écoulé avant les décès hospitaliers.

      Résultats

      Au total, 351 patients (4,8 %) sont décédés à l’hôpital. L’âge moyen était de 72,0 ± 12,4 ans et 40,5 % des patients étaient des femmes. La survie médiane était de 5 jours (intervalle interquartile : 2-12) et 41 % des décès hospitaliers sont survenus après 1 semaine. Les biomarqueurs cardiaques et la fraction d’éjection n’étaient pas liés au temps écoulé avant les décès hospitaliers. Des différences existaient entre les 4 groupes en ce qui concerne les antécédents d’IM, la pression artérielle systolique, la pharmacothérapie et les traitements interventionnels. Les facteurs associés à la mortalité hospitalière tardive comprenaient le pontage aortocoronarien (PAC), la fibrillation atriale ou le flutter atrial d’apparition récente, l’insuffisance cardiaque ou l’œdème pulmonaire, le saignement et les pneumopathies. La mortalité hospitalière aiguë et subaiguë était associée à l’IM avec sus-décalage du segment ST, à l’abaissement de la pression artérielle systolique et à l’arrêt cardiaque à l’admission. Un PAC avait été pratiqué après l’IM chez 12 % des patients décédés à l’hôpital.

      Conclusions

      Les facteurs de risque cliniques de mortalité hospitalière évoluent au fil du temps immédiatement après un IM aigu. La connaissance des facteurs de risque chronodépendants peut permettre l’élaboration de nouvelles approches visant à limiter la mortalité hospitalière « tardive ».

      Graphical abstract

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      Linked Article

      • Did We “OBTAIN” New Insights for Optimal Timing of CABG and Survival After Acute Myocardial Infarction?
        Canadian Journal of Cardiology
        • Preview
          Despite decades of therapeutic advancements in coronary revascularization—whether by thrombolysis, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG) surgery—and hemodynamic support with temporary mechanical circulatory support (tMCS) for those with further complication of shock, acute myocardial infarction (AMI) remains a leading cause of death in Canada and worldwide.1,2 Nearly 70,000 Canadians suffer from AMI, and 5000 die annually within 30 days of admission.2 Emergent CABG is still indicated for those patients with mechanical complications or severe ventricular failure leading to refractory cardiogenic shock (CS), heart failure (HF), or angina post-AMI, but the optimal timing of such surgical coronary revascularization in more stable or less symptomatic patients with AMI remains unclear.
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