Original article
New-onset heart failure after acute coronary syndrome in patients without heart failure or left ventricular dysfunctionInsuficiencia cardiaca de novo tras un síndrome coronario agudo en pacientes sin insuficiencia cardiaca ni disfunción ventricular izquierda

https://doi.org/10.1016/j.rec.2020.03.011Get rights and content

Abstract

Introduction and objectives

Coronary heart disease is the leading cause of heart failure (HF). The aim of this study was to assess the risk of readmission for HF in patients with acute coronary syndrome without previous HF or left ventricular dysfunction.

Methods

Prospective study of consecutive patients admitted for acute coronary syndrome in 2 institutions. Risk factors for HF were analyzed by competing risk regression, taking all-cause mortality as a competing event.

Results

We included 5962 patients and 567 (9.5%) experienced at least 1 hospital readmission for acute HF. Median follow-up was 63 months and median time to HF readmission was 27.1 months. The cumulative incidence of HF was higher than mortality in the first 7 years after hospital discharge. A higher risk of HF readmission was associated with age, diabetes, previous coronary heart disease, GRACE score > 140, peripheral arterial disease, renal dysfunction, hypertension and atrial fibrillation; a lower risk was associated with optimal medical treatment. The incidence of HF in the first year of follow-up was 2.73% and no protective variables were found. A simple HF risk score predicted HF readmissions risk.

Conclusions

One out of 10 patients discharged after an acute coronary syndrome without previous HF or left ventricular dysfunction had new-onset HF and the risk was higher than the risk of mortality. A simple clinical score can estimate individual risk of HF readmission even in patients without previous HF or left ventricular dysfunction.

Resumen

Introducción y objetivos

La cardiopatía isquémica es la primera causa de insuficiencia cardiaca. Nuestro objetivo es analizar el riesgo de insuficiencia cardiaca tras un síndrome coronario agudo en pacientes sin insuficiencia cardiaca previa ni disfunción ventricular izquierda.

Métodos

Estudio prospectivo de pacientes consecutivos ingresados por síndrome coronario agudo en 2 hospitales. La incidencia de insuficiencia cardiaca se analizó considerando la muerte como evento competitivo.

Resultados

Se incluyó a 5.962 pacientes, y 567 (9,5%) tuvieron al menos 1 reingreso por insuficiencia cardiaca aguda. La mediana de seguimiento fue 63 meses y la mediana de tiempo hasta el reingreso por insuficiencia cardiaca 27,1 meses. La incidencia acumulada de insuficiencia cardiaca fue superior que la de muerte en los primeros 7 años tras el alta. La edad, la diabetes, la cardiopatía isquémica previa, una escala GRACE > 140, la enfermedad arterial periférica, la disfunción renal, la hipertensión arterial y la fibrilación auricular se asociaron con mayor riesgo de reingreso por insuficiencia cardiaca; el tratamiento médico óptimo se asoció con menor riesgo. La incidencia de insuficiencia cardiaca en el primer año fue del 2,73% y no se hallaron variables protectoras. Una sencilla escala de riesgo de insuficiencia cardiaca predijo el riesgo de reingreso por insuficiencia cardiaca.

Conclusiones

Uno de cada 10 pacientes dados de alta tras un síndrome coronario agudo sin haber tenido antes insuficiencia cardiaca o disfunción ventricular sufrió insuficiencia cardiaca de novo y el riesgo es superior que el de muerte. Una sencilla escala clínica permite estimar el riesgo individual de reingreso por insuficiencia cardiaca, incluso en pacientes que no han tenido antes insuficiencia cardiaca ni disfunción ventricular izquierda.

Section snippets

INTRODUCTION

The incidence of chronic heart failure (HF) has increased exponentially in the last few decades1, 2 and therefore the detection of risk factors related to its incidence should be a primary target for research.3 Coronary heart disease is the leading cause of HF.1, 4 Acute coronary syndrome (ACS) is the most common presentation of coronary heart disease and produces the greatest myocardial damage. The presence of myocardial infarction, either as an ACS or as a silent event, increases the

Study design

We performed a prospective study of all consecutive patients admitted for ACS to 2 different centers between 2006 and 2016. A total of 8771 patients were admitted for ACS between November 2003 and December 2016. We excluded patients who died within the hospitalization (n = 450), those who developed HF during hospitalization (n = 1641), patients diagnosed with HF before the ACS hospitalization (n = 349), and those with LVEF < 0.50 measured in the index ACS. Finally, 5237 patients were included in the

RESULTS

We included 5962 patients discharged from hospital after an ACS and 567 (9.5%; 95%CI, 8.3-9.8) experienced at least 1 hospital readmission for acute HF during follow-up. The clinical features of the cohort are presented in table 1. Patients who developed HF had higher mean age, were more frequently female, and had a higher prevalence of cardiovascular risk factors and comorbidities. With regard to the index ACS, patients who developed postdischarge HF less frequently had ST-segment elevation

DISCUSSION

The objective of our study was to describe new-onset HF in patients discharged after an ACS, who are usually considered at low risk of HF as they do not have left ventricular dysfunction or previous HF. Nonetheless, the long-term follow-up in our study highlights that 10% of these patients developed new-onset HF and that many variables were positively associated with this highly important complication. HF within the first year after discharge was less common and was linked to just a few risk

CONFLICTS OF INTEREST

The authors declare that there are no conflicts of interest related to the results of this study.

WHAT IS KNOWN ABOUT THE TOPIC?

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    Coronary heart disease is the leading cause of HF.

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    HF during hospitalization for ACS is the main determinant of subsequent HF.

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    Onset of HF impairs prognosis and quality of life.

WHAT DOES THIS STUDY ADD?

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    One out of 10 patients will develop HF after ACS, despite not having left ventricular dysfunction or previous HF.

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    The risk of HF is higher than the risk of death in these patients.

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    Optimal medical treatment reduces the risk of HF

Acknowledgments

The authors of this study received support from the Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV CB16/11/00226 - CB16/11/00420), the national Spanish National Network for Biomedical Investigation on Cardiovascular Disease.

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