European Heart Journal Advance Access originally published online on April 1, 2009
European Heart Journal 2009 30(10):1195-1202; doi:10.1093/eurheartj/ehp099
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Prior polyvascular disease: risk factor for adverse ischaemic outcomes in acute coronary syndromes
1 VA Boston Healthcare System and Brigham and Women’s Hospital, Boston, MA, USA
2 Duke Clinical Research Institute, Durham, NC, USA
3 Brigham and Women’s Hospital, Boston, MA, USA
4 TIMI Study Group, Harvard Medical School, Boston, MA, USA
5 Beth Israel Deaconess Medical Center, Boston, MA, USA
6 The Methodist DeBakey Heart Center, Houston, TX, USA
7 Kaiser Permanente Health System, San Francisco, CA, USA
8 Cleveland Clinic, Cleveland, OH, USA
9 New York Methodist Hospital, Brooklyn, NY, USA
10 University of North Carolina, Chapel Hill, NC, USA
11 Pennsylvania Hospital, Philadelphia, PA, USA
12 University of Cincinnati, Cincinnati, OH, USA
Received 26 September 2008; revised 9 January 2009; accepted 26 February 2009; online publish-ahead-of-print 1 April 2009.
* Corresponding author. Tel: +1 617 525 9307, Fax: +1 617 732 7134, Email: dlbhattmd{at}alum.mit.edu
Aims: The presence of peripheral arterial disease (PAD) or cerebrovascular disease (CVD) is associated with higher likelihood of significant coronary artery disease (CAD). We sought to assess the prevalence of PAD, CVD, prior CAD, or pre-existent disease in multiple arterial territories (‘polyvascular’ disease) in patients presenting with non-ST-segment elevation acute coronary syndrome and its impact on adverse events.
Methods and results: Data from 95 749 patients enrolled from February 2003 to September 2006 at 484 sites in the CRUSADE registry were analysed. Patients were categorized as having prior 0, 1, 2, or 3 affected arterial beds. The rates of in-hospital mortality, myocardial infarction, stroke, and congestive heart failure were analysed, as were the rates of non-bypass surgery-related red blood cell transfusion and major bleeding. On presentation, 11 345 (11.9%) patients had established PAD, 9973 (10.4%) had documented CVD, and 41 404 (43.2%) had prior CAD. In this cohort, 0, 1, 2, and 3 arterial bed disease before presentation was present in 46 814 (48.9%, 95% CI 48.6–49.2%), 36 704 (38.3%, 95% CI 37.8–39.0%), 10 675 (11.2%, 95% CI 10.9–11.9%), and 1556 (1.6%, 95% CI 1.5–1.8%) patients, respectively. The rates of ischaemic events increased with the number of affected vascular beds. The adjusted odds ratio for the composite of in-hospital ischaemic events for pre-existent disease in 1, 2, or 3 arterial beds (compared with 0 arterial bed involvement) increased from 1.07 to 1.26 to 1.31 (P < 0.001). Similarly, the adjusted odds ratio for transfusion increased with greater disease burden from 1.11 to 1.28 to 1.30 (P < 0.001), although the adjusted rates of protocol-defined non-bypass surgery-related major bleeding did not.
Conclusion: Prior polyvascular disease increases the risk of in-hospital adverse events, including mortality. Identification of these patients in clinical trial and real world populations may provide an opportunity to reduce their excess risk with intensive secondary prevention efforts.
Key Words: Acute coronary syndromes • Coronary artery disease • Cerebrovascular disease • Peripheral arterial disease
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