Influence of invasive ischemic evaluation on mortality in patients with a new onset heart failure after myocardial infarction
M Ferreira, M Mendonca, F Escorcio Silva, F Sousa, G Abreu, E Henriques, S Freitas, M Rodrigues, S Borges, A Cardoso, I Ornelas, A Drumond, A C Sousa, R Palma dos ReisAbstract
Background
New-onset heart failure (HF) after myocardial infarction (MI) identifies a high-risk population with increased morbidity and mortality, for whom early invasive ischemic evaluation is recommended. However, referral rates remain suboptimal, suggesting a potential care gap.
Objective
Evaluate the proportion of patients who underwent invasive ischemic evaluation after hospitalisation for new-onset systolic HF following MI, and to assess its association with all-cause and cardiovascular mortality in a medium-income peripheral hospital.
Methods
This retrospective cohort study (2000–2019) included 1,720 patients with myocardial infarction (all with coronary obstruction ≥70% on angiography). We identified those who were subsequently admitted with HF with reduced ejection fraction (HFrEF; EF ≤40%) of recent onset and followed them prospectively for a median of 7.6±6.7 years. Patients were stratified by receipt of invasive ischemic evaluation (IE). Cox regression, adjusted for confounding (sex, age, diabetes, smoking, dyslipidemia, hypertension, obesity, sedentary lifestyle, and chronic kidney disease estimated by glomerular filtration rate (GFR)), assessed the independent association with all-cause mortality and cardiovascular mortality. Kaplan-Meier curves assessed survival.
Results
Of 1,720 MI patients, 257 (15%) developed HFrEF. Among them, 146 (56.8%) underwent invasive IE. Absence of IE and diabetes were independently associated with higher all-cause and cardiovascular mortality. Patients without Ischemic evaluation (IE) had increased all-cause mortality (HR=1.67; 95% CI 1.21–2.29; p=0.002) and cardiovascular mortality (HR=1.55; 95% CI 1.11–2.17; p=0.009). Diabetes was also associated with higher all-cause mortality (HR=1.49; 95% CI 1.11–2.01; p=0.008) and cardiovascular mortality (HR=1.50; 95% CI 1.11–2.06; p=0.012). At approximately 12 years, patients without IE had higher all-cause (71.1% vs 47.9%) and cardiovascular mortality (65.1% vs 45.4%).
Conclusion
Patients admitted with heart failure with reduced ejection fraction of recent onset after myocardial infarction (MI) remain at high risk of long-term mortality. Early ischemic evaluation with coronary angiography was associated with lower all-cause mortality, cardiovascular death, and HF readmissions by improving residual obstructive disease and reducing progression of heart failure.Ischemic evaluation 1Ischemic evaluation 2