Impact of polyvascular disease on baseline characteristics, management and mortality in acute myocardial infarction. The Alliance project.

BACKGROUND: A substantial number of patients with acute myocardial infarction (AMI) have polyvascular disease (PolyVD), defined as cerebrovascular disease (CVD), peripheral arterial disease (PAD) or both. AIM: To investigate the impact of PolyVD on baseline characteristics, management and outcomes.
METHODS: The Alliance project is a multicentre, cross-sectional database of patients with myocardial infarction throughout France from 2000 to 2005. A pooled analysis of individual patient data was performed by aggregating data from five registries, representing 9783 patients hospitalized for acute coronary syndromes. Data were collected on history of PAD and CVD and correlated to baseline characteristics, management and hospital outcomes.
RESULTS: Eight thousand nine hundred and four patients had full datasets for this analysis (13% with a history of CVD or PAD, 87% without). Patients with PolyVD were older (72 vs 65 years, p<0.0001), had a more frequent history of AMI (26% vs 15%, p<0.0001), percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), renal insufficiency (12% vs 3%, p<0.0001) and consistently more risk factors for atherosclerosis (hypertension, dyslipidaemia, smoking, diabetes), but less frequently a body mass index>30 kg/m(2) (14.0% vs 20.1%, p<0.0001) compared to patients with coronary artery disease (CAD) alone. Killip class, left-ventricular ejection fraction and GUSTO risk score were all worse among patients with PolyVD. Management of patients with PolyVD was less aggressive (with later admission and less frequent use of in-hospital angiography or evidence-based therapies at discharge). Mortality of patients with PolyVD was consistently higher than in those with CAD alone, regardless of age. Multivariable analysis, adjusting for age, showed that both PAD (odds ratio 1.36 95% confidence interval 1.03-1.79) and history of CVD (odds ratio 1.74, 95% confidence interval 1.27-2.40) were independent predictors of hospital mortality relative to patients with CAD only.
CONCLUSION: Patients with PolyVD represented a substantial group among AMI patients, at particularly high risk of death, yet were managed less aggressively than patients with CAD alone. This was associated with markedly higher in-hospital mortality. Further research is warranted to design and test strategies to decrease mortality in this high-risk subset. Copyright 2010. Published by Elsevier Masson SAS.