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Coronary artery disease
Original research article
Combined association of key risk factors on ischaemic outcomes and bleeding in patients with myocardial infarction
  1. Daniel Lindholm1,
  2. Giovanna Sarno2,
  3. David Erlinge3,
  4. Bodil Svennblad4,
  5. Lars Pål Hasvold5,
  6. Magnus Janzon6,
  7. Tomas Jernberg7,
  8. Stefan K James4
  1. 1 AstraZeneca R&D, Gothenburg, Sweden
  2. 2 Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
  3. 3 Department of Cardiology, Lund University, Lund, Sweden
  4. 4 Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
  5. 5 Medical Department, AstraZeneca, Sodertalje, Sweden
  6. 6 Department of Medical and Health Sciences, Department of Cardiology, Linköping University, Linköping, Sweden
  7. 7 Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
  1. Correspondence to Dr Stefan K James, Cardiology, Department of Medical Sciences, Uppsala Clinical Research Cente, Uppsala University, Uppsala SE-751 85, Sweden; stefan.james{at}ucr.uu.se

Abstract

Objective In patients with myocardial infarction (MI), risk factors for bleeding and ischaemic events tend to overlap, but the combined effects of these factors have scarcely been studied in contemporary real-world settings. We aimed to assess the combined associations of established risk factors using nationwide registries.

Methods Using the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry, patients with invasively managed MI in 2006–2014 were included. Six factors were assessed in relation to cardiovascular death (CVD)/MI/stroke, and major bleeding: age ≥65, chronic kidney disease, diabetes, multivessel disease, prior bleeding and prior MI.

Results We studied 100 879 patients, of whom 20 831 (20.6%) experienced CVD/MI/stroke and 5939 (5.9%) major bleeding, during 3.6 years median follow-up. In adjusted Cox models, all factors were associated with CVD/MI/stroke, and all but prior MI were associated with major bleeding. The majority (53.5%) had ≥2 risk factors. With each added risk factor, there was a marked but gradual increase in incidence of the CVD/MI/stroke. This was seen also for major bleeding, but to a lesser extent, largely driven by prior bleeding as the strongest risk factor.

Conclusions The majority of patients with MI had two or more established risk factors. Increasing number of risk factors was associated with higher rate of ischaemic events. When excluding patients with prior major bleeding, bleeding incidence rate increased only minimally with increasing number of risk factors. The high ischaemic risk in those with multiple risk factors highlights an unmet need for additional preventive measures.

  • risk factors
  • acute coronary syndromes

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/heartjnl-2018-314590

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    Footnotes

    • Contributors Conception and design: DL, DE, BS, LPH, MJ, TJ, SKJ. Analysis and interpretation of data: DL, DE, BS, LPH, MJ, TJ, SKJ. Drafting the article: DL. Revising the article: DL, GS, DE, BS, LPH, MJ, TJ, SKJ. Provided intellectual content of critical importance to the work described: all authors. Final approval of the version to be published: all authors.

    • Funding This study was supported by AstraZeneca.

    • Competing interests DL reports being an employee at Uppsala University and affiliated with Uppsala Clinical Research Center during the time this work was conducted, but has since been employed by AstraZeneca. BS reports institutional research grants from AstraZeneca, Novartis and Abbott. LPH reports being employed by AstraZeneca. MJ reports lecture fees from AstraZeneca and Pfizer. TJ has received consultant and lecture fees from AstraZeneca, MSD and Aspen. SKJ reports institutional research grants from AstraZeneca.

    • Ethics approval The study was approved by the Ethics Committee in Uppsala.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Data supporting the conclusions in this article and additional data are available upon request. Please contact the corresponding author.

    • Patient consent for publication Not required.

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