Prognostic impact of anaemia on patients with ST-elevation myocardial infarction treated by primary PCI.
TL;DR: Although anaemia (based on the WHO definitions) does not appear to be an independent predictor of all-cause mortality or major adverse cardiac events after PPCI on multivariate analysis, there appears to be a threshold value of Hb among men, below which there is an associated increased risk for PPCi.
Abstract: AIM The aim of this study was to investigate the effects of baseline anaemia on the outcome in patients treated by primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction. METHODS This study was a retrospective cohort study of 2418 patients with ST-elevation myocardial infarction treated by PPCI between January 2004 and August 2010 at a single centre. We investigated the outcome in patients with anaemia compared with that in patients with a normal haemoglobin (Hb) level. Anaemia was defined according to the WHO definition as an Hb level less than 12 g/dl for female individuals and less than 13 g/dl for male individuals. We also calculated hazard ratios using a stratified model according to the Hb level. RESULTS A total of 471 (19%) patients were anaemic at presentation. The anaemic cohort was older (72.2 vs. 62.4 years, P<0.0001) and had a higher incidence of diabetes (28 vs. 16%, P<0.0001), hypertension (57 vs. 43%, P=0.01), hypercholesterolaemia (48 vs. 40%, P=0.007), previous PCI (15 vs. 9%, P<0.0001), previous myocardial infarction (23 vs. 12%, P=0.002), and cardiogenic shock (12 vs. 5%, P<0.0001). Over a mean follow-up period of 3 years there was significantly higher all-cause mortality in the anaemic group compared with the normal Hb group (20.4 vs. 13.5%, P<0.0001). However, after adjustment for all variables using multivariate analysis, anaemia (on the basis of the WHO definitions) was found not to be an independent predictor of mortality or major adverse cardiac events over the follow-up period. Further, when we used a model stratified by g/dl, we found that there was an increased risk for adverse outcomes among men with low Hb levels. There appeared to be a threshold value of Hb (13 g/dl) associated with increased risk. Although a similar trend was observed among women, no significant difference was observed. CONCLUSION Patients with anaemia undergoing PPCI are at a higher risk of an adverse outcome. Anaemia is a simple and powerful marker of poor prognosis. Although anaemia (based on the WHO definitions) does not appear to be an independent predictor of all-cause mortality or major adverse cardiac events after PPCI on multivariate analysis, there appears to be a threshold value of Hb among men, below which there is an associated increased risk for PPCI.
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TL;DR: In routine clinical practice, major bleeding is a relatively frequent non-cardiac complication of contemporary therapy for ACS and it is associated with a poor hospital prognosis and it was significantly associated with an increased risk of hospital death.
Abstract: AIMS
There have been no large observational studies attempting to identify predictors of major bleeding in patients with acute coronary syndromes (ACS), particularly from a multinational perspective. The objective of our study was thus to develop a prediction rule for the identification of patients with ACS at higher risk of major bleeding.
METHODS AND RESULTS
Data from 24045 patients from the Global Registry of Acute Coronary Events (GRACE) were analysed. Factors associated with major bleeding were identified using logistic regression analysis. Predictive models were developed for the overall patient population and for subgroups of patients with ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. The overall incidence of major bleeding was 3.9% (4.8% in patients with STEMI, 4.7% in patients with NSTEMI and 2.3% in patients with unstable angina). Advanced age, female sex, history of bleeding, and renal insufficiency were independently associated with a higher risk of bleeding (P<0.01). The association remained after adjustment for hospital therapies and performance of invasive procedures. After adjustment for a variety of potential confounders, major bleeding was significantly associated with an increased risk of hospital death (adjusted odds ratio 1.64, 95% confidence interval 1.18, 2.28).
CONCLUSIONS
In routine clinical practice, major bleeding is a relatively frequent non-cardiac complication of contemporary therapy for ACS and it is associated with a poor hospital prognosis. Simple baseline demographic and clinical characteristics identify patients at increased risk of major bleeding.
466 citations
TL;DR: This review aims to clarify poorly investigated and defined issues concerning the relation of anemia and cardiovascular risk--in particular in patients with acute coronary syndromes and chronic heart failure--as well as the current therapeutic strategies in these clinical conditions.
58 citations
TL;DR: The prevalence of anemia in contemporary cohorts of patients undergoing PCI is significant and is associated with significant increases in postprocedural mortality, MACE, reinfarction, and bleeding.
Abstract: Anemia is common in patients undergoing percutaneous coronary intervention (PCI), and current guidelines fail to offer recommendations for its management. This review aims to examine the relation between baseline anemia and mortality, major adverse cardiovascular events (MACE), and major bleeding in patients undergoing PCI. We searched MEDLINE and EMBASE for studies that evaluated mortality and adverse outcomes in anemic and nonanemic patients who underwent PCI. Data were collected on study design, participant characteristics, definition of anemia, follow-up, and adverse outcomes. Random effects meta-analysis of risk ratios was performed using inverse variance method. A total of 44 studies were included in the review with 230,795 participants. The prevalence of baseline anemia was 26,514 of 170,914 (16%). There was an elevated risk of mortality and MACE with anemia compared with no anemia-pooled risk ratio (RR) 2.39 (2.02 to 2.83), p <0.001 and RR 1.51 (1.34 to 1.71), p <0.001, respectively. The risk of myocardial infarction and bleeding with anemia compared with no anemia was elevated, pooled RR 1.33 (1.07 to 1.65), p = 0.01 and RR 1.97 (1.03 to 3.77), p <0.001, respectively. The risk of mortality per unit incremental decrease in hemoglobin (g/dl) was RR 1.19 (1.09 to 1.30), p <0.001 and the risk of mortality, MACE, and reinfarction per 1 unit incremental decrease in hematocrit (%) was RR 1.07 (1.05 to 1.10), p = 0.04, RR 1.09 (1.08 to 1.10) and RR 1.06 (1.03 to 1.10), respectively. The prevalence of anemia in contemporary cohorts of patients undergoing PCI is significant and is associated with significant increases in postprocedural mortality, MACE, reinfarction, and bleeding. The optimal strategy for the management of anemia in such patients remains uncertain.
54 citations
TL;DR: In this large population with stable coronary artery disease, low hemoglobin was an independent predictor of mortality, cardiovascular events, and major bleeds and Persisting or new-onset anemia is a powerful predictor of cardiovascular and noncardiovascular mortality.
36 citations
Cites background or result from "Prognostic impact of anaemia on pat..."
...Many of these were single center experiences.(2,18,19) Anemia at baseline has consistently been shown to predict adverse outcome....
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...In keeping with other studies, patients with higher baseline hemoglobin were younger and more likely to be male.(5,18) Comorbidities were more prevalent in patients with lower hemoglobin and this was particularly noticeable for diabetes; patients in the lowest quintile of hemoglobin were nearly twice as likely to be diabetic as compared to those in the highest quintile....
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TL;DR: It is suggested that anemic ST-segment–elevation myocardial infarction patients may safely receive timely primary percutaneous coronary intervention but with particular consideration for bleeding avoidance strategies.
Abstract: Background: Anemia may confer a poor prognosis among patients with the acute coronary syndrome. However, few data exist on the association of anemia with in-hospital outcomes, including bleeding, a...
27 citations
References
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TL;DR: ‘Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes’ recently published in European Heart Journal 1 rightly dedicates space to the pitfalls that can be encountered when reading presentation ECGs, but there is an important omission.
Abstract: ‘Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology’ recently published in European Heart Journal 1 rightly dedicates space to the pitfalls that can be encountered when reading presentation ECGs. However, we wish to draw attention to what we think is an important omission. No reference is made in this context to acute aortic syndrome (AAS)—a condition in …
669 citations
TL;DR: In routine clinical practice, major bleeding is a relatively frequent non-cardiac complication of contemporary therapy for ACS and it is associated with a poor hospital prognosis and it was significantly associated with an increased risk of hospital death.
Abstract: AIMS
There have been no large observational studies attempting to identify predictors of major bleeding in patients with acute coronary syndromes (ACS), particularly from a multinational perspective. The objective of our study was thus to develop a prediction rule for the identification of patients with ACS at higher risk of major bleeding.
METHODS AND RESULTS
Data from 24045 patients from the Global Registry of Acute Coronary Events (GRACE) were analysed. Factors associated with major bleeding were identified using logistic regression analysis. Predictive models were developed for the overall patient population and for subgroups of patients with ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina. The overall incidence of major bleeding was 3.9% (4.8% in patients with STEMI, 4.7% in patients with NSTEMI and 2.3% in patients with unstable angina). Advanced age, female sex, history of bleeding, and renal insufficiency were independently associated with a higher risk of bleeding (P<0.01). The association remained after adjustment for hospital therapies and performance of invasive procedures. After adjustment for a variety of potential confounders, major bleeding was significantly associated with an increased risk of hospital death (adjusted odds ratio 1.64, 95% confidence interval 1.18, 2.28).
CONCLUSIONS
In routine clinical practice, major bleeding is a relatively frequent non-cardiac complication of contemporary therapy for ACS and it is associated with a poor hospital prognosis. Simple baseline demographic and clinical characteristics identify patients at increased risk of major bleeding.
466 citations
TL;DR: In this article, the authors assessed baseline hemoglobin quintiles and anemia in relation to mortality in the Cardiovascular Health Study, a prospective cohort study with 11.2 years of follow-up of 5888 community-dwelling men and women 65 years or older, enrolled in 1989-1990 or 1992-1993 in 4 US communities.
Abstract: Background Anemia is viewed as a negative prognostic factor in the elderly population; its independent impact on survival is unclear. Methods Baseline hemoglobin quintiles and anemia, as defined by the World Health Organization criteria, were assessed in relation to mortality in the Cardiovascular Health Study, a prospective cohort study with 11.2 years of follow-up of 5888 community-dwelling men and women 65 years or older, enrolled in 1989-1990 or 1992-1993 in 4 US communities. Results A total of 1205 participants were in the lowest hemoglobin quintile ( Conclusions Lower and higher hemoglobin concentrations and anemia by World Health Organization criteria were independently associated with increased mortality. The World Health Organization criteria did not identify risk as well as a lower hemoglobin value. Additional study is needed on the clinically valid definition for and causes of anemia in the elderly and on the increased mortality at the extremes of hemoglobin concentrations.
434 citations
TL;DR: A four- to five-fold increase in the risk of death, MI, and stroke at 30 days has been observed in patients with bleeding events, as compared to those without, both in the short- and long-term.
Abstract: Over the last two decades, major improvements in clinical outcome have been achieved in the management of acute coronary syndromes (ACS), with or without ST-segment elevation. In both these clinical settings, the pharmacological approach comprising anti-platelet agents, (or a combination thereof), anticoagulants, thrombolytic treatment in case of ST-elevation MI (STEMI) combined with mechanical or surgical revascularization or reperfusion, has led to a dramatic reduction in the rate of ischaemic events, namely death, death/myocardial infarction (MI), or death/MI/stroke. However, this has been achieved at the cost of a higher risk of bleeding complications, which were considered, until recently, to be inherent to ACS management, and to be a side effect devoid of serious clinical implications, except for intra-cranial bleeding. Bleeding complications were thought to be the price to pay for the improvement in the risk of ischaemic events, and were considered to be easily controlled, particularly thanks to a liberal transfusion policy. In this context, the risk factors for bleeding have been identified, and include baseline characteristics, such as age, female gender, renal failure, diabetes, and heart failure. In addition, the number and dosage of anti-thrombotic drugs, the use of fibrinolytic treatments, and the use of invasive strategies, required to achieve mechanical reperfusion or revascularization, also play an important role.1,2
However, over the last 5 years, it has become clear that bleeding complications occurring during the initial phase of ACS have a considerable impact on prognosis, especially in terms of death, MI, and stroke, both in the short- and long-term. A four- to five-fold increase in the risk of death, MI, and stroke at 30 days has been observed in patients with bleeding events, as compared to those without.2–4
The potential mechanisms by which …
Corresponding author. Tel: +33 381 668 539; fax: +33 381 668 582. E-mail address : jpbassan{at}univ-fcomte.fr
357 citations
TL;DR: Anemia at baseline in patients with AMI undergoing primary PCI is common, and is strongly associated with adverse outcomes and increased mortality, and was an independent predictor of in-hospital mortality.
245 citations