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Modes and Timing of Death in NSTE-ACS Patients
Study Questions:
What are the modes of death following non-ST-segment elevation acute coronary syndromes (NSTE-ACS) in clinical trial populations?
Methods:
The investigators evaluated 66,252 patients with NSTE-ACS enrolled in 14 TIMI (Thrombolysis in Myocardial Infarction) trials, examining baseline characteristics and modes and timing of death. The cumulative mortality rates of all NSTE-ACS patients in the merged database were calculated by the complement of Kaplan–Meier survival estimates. Both the general class and specific mode of death were stratified according to timing of death relative to the date of randomization, with prespecified time intervals of 0–30 days and >30 days.
Results:
Of the 66,252 patients followed for a median of 372 (interquartile range, 218-521) days, 3,147 (4.8%) died by the time of last follow-up. Of the 2,606 patients (82.8%) with known modes of death, 75.1% were related to a cardiovascular (CV) event, 3.0% were related to a bleeding event (including intracranial hemorrhage), and 21.8% were related to a non-CV/nonbleeding event. The most common modes of CV death were sudden death and recurrent myocardial infarction (MI) (36.4% and 23.4%, respectively, of CV deaths). The proportion of CV deaths related to recurrent MI was higher in the first 30 days than it was after 30 days following NSTE-ACS (30.6% vs. 18.7%), whereas the proportion of sudden death was lower in the first 30 days than after 30 days (21.6% vs. 46.2%).
Conclusions:
The authors concluded that sudden death represents the largest proportion of CV deaths after 30 days among patients enrolled in CV clinical trials with NSTE-ACS.
Perspective:
This study reports that three-fourths of deaths in patients with NSTE-ACS enrolled in TIMI trials were related to CV modes, although the relative proportion of CV deaths decreased with time following the event. Recurrent MI represented the largest proportion of CV deaths in the first 30 days following trial enrollment for NSTE-ACS, whereas sudden death was a proportionately greater mode of CV death after 30 days. Additional studies are indicated to define the epidemiology and pathophysiology of sudden death following NSTE-ACS, and we need to develop specific therapies and management approaches to reduce sudden death to impact and reduce late mortality after NSTE-ACS.
Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Death, Sudden, Hemorrhage, Intracranial Hemorrhages, Myocardial Infarction, Secondary Prevention
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