PREDICTORS OF PROGRESSION TO SEVERE HEART FAILURE IN NON-ST-

SEGMENT ELEVATION ACUTE CORONARY SYNDROME.

RESULTS FROM THE ARIAM-REGISTRY

Alejandro Espínola PardoHospital Virgen Macarena

Sevilla

DECLARATION OF INTEREST

• I HAVE NOTHING TO DECLARE.

INTRODUCTION AND PURPOSE

Guidelines strongly recommend the use of risk scores in the setting of Non-ST Myocardial Infarction (NSTEMI).

Despite all, there are not scores for AHF in non-ST acute coronary syndrome.

We are willing to identify, by means of our population, clinical features easily measurable at admission, which predict the development of severe heart failure in the setting of non-ST-ACS.

Acute heart failure (AHF) complicates a great proportion of Non-ST-elevation acute coronary syndromes and increases mortality.

Comparisons in mortality according to Killip classes in Non-ST MI in different studies. From: Ayman El-Menyar MBChB. American Journal of Emergency Medicine (2012) 30, 97–103

TIMI risk score por UA/NSTEMI TIMI RISK FACTORS• Age ≥ 65 yrs• ≥ 3 CAD risk factors• Known CAD(> 50% stenosis)• Prior aspirin• ≥ 2 anginal episodes in prior 24 hr• ≥ ST deviation ³ 0.5 mm ofpresenting ECG• ­↑Cardiac markers

METHODS

Retrospective analysis of multicentric, ARIAM-registry (Registro  de Análisis  del  Retraso en  el  Infarto Agudo de Miocardio)

10160 patients without heart failure (Killip class I at admission), admitted for Non-ST ACS at intensive care units in Andalusia, enrolled from 2001-2012.

Demographics, medical history and characteristics at presentation were studied in patients who developed severe heart failure (Killip class III-IV) (AHF group) and those who not.

Statistical analysis: SPSS™

RESULTS210 patients (2.1%) showed severe heart failure, Killip III-IV, from a Killip I class at admission. These were older, with no differences acording to gender. Baseline characteristics:

Multivariable logistic regression model found Age, Diabetes, Peripheral artery disease, diuretics and heart rate predictive factors for progression to severe heart failure

ODDS RATIO 95% IC P VALUE

Age 1,043 1,026-1,061 <0,001Diabetes 1,504 1,106-2,046 =0,009

Peripheral Artery Disease 1,703 1,077-2,695 =0,023

Diuretics 1,479 1,038-2,107 =0,03Heart Rate 1,009 1,001-1,016 =0,032

MAX Killip 1-2

MAX Killip 3-4 P VALUE

MO

RTALITY

ICU 0,5 % 31,4% p < 0,001

HOSPITAL 1% 33,8% p < 0,001

MAX Killip 1-2

MAXKillip 3-4

AGE, yrsmedian(IC 95%)

64,4 70,34 ANOVAp < 0,001

(64,2-64,7) (69,4-72,1)

GENDER, %M/F 98 / 97,7 2 / 2,3 χ2

P=0,47MEDICAL HISTORY MAX

Killip 1-2MAX

Killip 3-4χ2

Smokers/No 98,6/97,7 1,4/2,3 P=0,005

Diabetes/No 96,8/98,5 3,2/1,5 P<0.001

Hypertension/No 97,7/98,3 2,3/1,7 P=0,017

Myocardial infarction/No 97,3/98,1 2,7/1,9 P=0,017

Heart failure/No 95,4/98 4,6/2 P<0.001

Stroke/No 95,9/98,1 4,1/1,9 P<0,001

Arrhytmia/No 96,5/98,1 3,5/1,9 P=0.003

Peripheral artery disease/No

94,8/98,1 5,2/1,9 P<0.001

Obstructive pulmonary disease/No

96,4/98 3,6/2 P=0,013

Renal disfunction/No 94,4/98 5,6/2 P>0.001

TREATMENT MAXKillip 1-2

MAXKillip 3-4

χ2

Antiplatelets 96,7/98,2 3,3/1,8 p<0.001

Beta-Blockers 97,3/98,2 2,7/1,8 p=0.005

Renin-Angiotensin

inhibitors

97,3/98,3 2,7/1,7 p>0.001

Antiarrhytmics 93,9/98 6,1/2 p=0,01

Nitrates 96,7/98,3 3,3/1,7 P>0,001

Anticoagulants 96/98,1 4/1,9 P>0.001

Diuretics 96,2/98,3 3,8/1,7 P>0.001

AHF group had greater mortality, both in ICU and in-hospital.

Hosmer and Lemeshow test: p=0,7; c-statistic= 0,81

CONCLUSIONS AND LIMITATIONSHeart failure complicating NSTEMI carries much worse prognosis.

According to this model, age, diabetes, peripheral artery disease, previous diuretic treatment and tachycardia at admission are independent predictors for progression to AHF Killip III-IV.

Identifying these features in NSTEMI patients could be useful in their management, and we could easily estimate a risk score to predict this severe complication.

LIMITATIONS

• Registry.

• Retrospective analysis, case-control

• Bias: selection, omitted variable…

Muchas gracias