Stroke Risk in Patients With Reduced Ejection Fraction After Myocardial Infarction Without Atrial Fibrillation

Journal of the American College of Cardiology

Volume 71, Issue 7, February 2018 DOI: 10.1016/j.jacc.2017.12.011

João Pedro Ferreira, Nicolas Girerd, John Gregson, Ichraq Latar, Abhinav Sharma, Marc A. Pfeffer, John J.V. McMurray, Azmil H. Abdul-Rahim, Bertram Pitt, Kenneth Dickstein, Patrick Rossignol, Faiez Zannad and for the High-Risk Myocardial Infarction Database Initiative

Abstract

Background Stroke can occur after myocardial infarction (MI) in the absence of atrial fibrillation (AF).

Objectives This study sought to identify risk factors (excluding AF) for the occurrence of stroke and to develop a calibrated and validated stroke risk score in patients with MI and heart failure (HF) and/or systolic dysfunction.

Methods The datasets included in this pooling initiative were derived from 4 trials: CAPRICORN (Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction), OPTIMAAL (Optimal Trial in Myocardial Infarction With Angiotensin II Antagonist Losartan), VALIANT (Valsartan in Acute Myocardial Infarction Trial), and EPHESUS (Eplerenone Post–Acute Myocardial Infarction Heart Failure Efficacy and Survival Study); EPHESUS was used for external validation. A total of 22,904 patients without AF or oral anticoagulation were included in this analysis. The primary outcome was stroke, and death was treated as a “competing risk.”

Results During a median follow-up of 1.9 years (interquartile range: 1.3 to 2.7 years), 660 (2.9%) patients had a stroke. These patients were older, more often female, smokers, and hypertensive; they had a higher Killip class; a lower estimated glomerular filtration rate; and a higher proportion of MI, HF, diabetes, and stroke histories. The final stroke risk model retained older age, Killip class 3 or 4, estimated glomerular filtration rate ≤45 ml/min/1.73 m², hypertension history, and previous stroke. The models were well calibrated and showed moderate to good discrimination (C-index = 0.67). The observed 3-year event rates increased steeply for each sextile of the stroke risk score (1.8%, 2.9%, 4.1%, 5.6%, 8.3%, and 10.9%, respectively) and were in agreement with the expected event rates.

Conclusions Readily accessible risk factors associated with the occurrence of stroke were identified and incorporated in an easy-to-use risk score. This score may help in the identification of patients with MI and HF and a high risk for stroke despite their not presenting with AF.

Listen to this manuscript’s audio summary by JACC Editor-in-Chief Dr. Valentin Fuster.

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Source: http://www.onlinejacc.org/content/71/7/727

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