Effect of Prior Stroke on the Use of Evidence-Based Therapies and In-Hospital Outcomes in Patients With Myocardial Infarction (From the NCDR ACTION GWTG Registry)

Study Questions:

How useful are evidence-based medications with regard to the outcomes in patients with prior stroke who present with ST-elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI)?

Methods:

Data were collected from 281 hospitals in the United States in the NCDR ACTION Registry. The authors assessed the outcome of patients with STEMI (n = 15,997) or NSTEMI ( n = 25,514), and compared those with prior stroke to those without a documented history of prior stroke. The outcomes of interest were use of evidence-based medications and risk-adjusted odds of death, major bleeding not related to coronary artery bypass grafting, and major adverse cardiac events (MACE; composite of death/MI/stroke/cardiogenic shock/congestive heart failure).

Results:

A history of prior stroke was present in 5.1% of patients with STEMI and 9.3% of those with NSTEMI. Among patients presenting with STEMI and eligible for reperfusion therapy, those with previous stroke were less likely to receive reperfusion therapy compared to patients without previous stroke (87.3% vs. 94.9%), and had longer door-to-needle (47 vs. 35 minutes) and door-to-balloon times (81 vs. 75 minutes). Those with previous stroke were less likely to receive evidence-based therapies at discharge (statin 87.1% vs. 91.7%, clopidogrel 85.9% vs. 90.7%). Death (10.8% vs. 4.1%), MACE (25.6% vs. 11.9%), and major bleeding (14.6% vs. 10.5%) were more common with previous stroke. After adjusting for baseline risk, patients with previous stroke remained at increased risk of MACE (odds ratio, 1.43; 95% confidence interval, 1.17-1.75).

Conclusions:

The authors concluded that patients with a history of prior stroke are at increased risk of adverse outcomes after presenting with STEMI and NSTEMI.

Perspective:

This study demonstrates a robust association between a prior history of a stroke and adverse outcome in patients with acute coronary syndrome. It is not clear if more aggressive antithrombotic/antiplatelet therapy can reduce the event rate further since this subgroup had worse outcomes with prasugrel compared with clopidogrel (N Engl J Med 2007;357:2001-15) in the TRITON-TIMI 38 trial. However, the dramatic underuse of statins in this population is clearly an opportunity for improvement, and provides a ripe target for dedicated quality improvement efforts. Further data are needed to define the best therapeutic strategy for patients with prior stroke who present with acute coronary syndrome.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Heart Failure, Piperazines, United States


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