Impact of concomitant aortic stenosis on in-hospital outcomes in non-ST-elevation myocardial infarction

Background

In an aging population, concomitant valvular heart disease is increasingly prevalent. While aortic stenosis (AS) is a known driver of reduced life expectancy, its specific impact on the prognosis of patients presenting with non-ST-elevation myocardial infarction (NSTEMI) remains insufficiently characterized. This study sought to determine whether AS severity independently exacerbates NSTEMI outcomes, focusing on in-hospital mortality and major complications.

Methods

Consecutive NSTEMI patients referred for coronary angiography were prospectively enrolled in a single-center, all-comers, real-world registry. AS severity was stratified by initial transthoracic echocardiography, typically performed in the emergency department before angiography or, if deferred for urgent invasive management, afterwards in the coronary care unit. Adverse in-hospital events were a composite of in-hospital all-cause death, cardiogenic shock, and mechanical ventilation. To determine the independent association between AS and in-hospital outcomes a regression analysis adjusting for age, sex, cardiovascular risk factors, comorbidities, troponin, ejection fraction, myocardial infarction type, culprit lesion diameter stenosis and culprit vessel was performed. The final multivariable regression model exclusively included covariates that demonstrated statistical significance in the preliminary univariable analysis.

Results

Of 1414 registry patients, 1380 underwent echocardiographic assessment of the aortic valve and comprised the study cohort. The median age was 70 (IQR 60–79) years, and 414 (30.0%) were female. Regarding AS severity, 1232 (89.3%) patients had no AS, while 45 (3.3%), 52 (3.8%), and 51 (3.7%) had mild, moderate, and severe AS, respectively. Increasing AS severity was associated with older age (p<0.001), higher creatinine levels (p<0.001), lower hemoglobin (p<0.001), and lower ejection fraction (p=0.007). No significant difference in peak troponin was observed across AS classifications (p = 0.132), however.

Adverse in-hospital events occurred in 14.9% of patients with no AS, 17.8% with mild, 23.1% with moderate, and 37.3% with severe AS (p < 0.001). In-hospital mortality rates were 5.0%, 8.9%, 15.4%, and 23.5% across the respective groups (p < 0.001). Following multivariable adjustment, severe AS remained independently associated with both adverse in-hospital events (OR 2.1, 95% CI 1.1–4.0, p=0.031) and in-hospital death (OR 2.8, 95% CI 1.2–6.1, p=0.011).

Conclusions

Concomitant severe AS is independently associated with significantly worse outcomes and increased mortality in patients presenting with NSTEMI. Hence, patients with severe aortic stenosis at high risk for acute coronary syndromes might benefit from early interventional or surgical treatment to mitigate adverse outcomes and improve overall prognosis.Figure