Author + information
- Received September 27, 2017
- Revision received December 5, 2017
- Accepted December 6, 2017
- Published online February 12, 2018.
- João Pedro Ferreira, MD, PhDa,b,
- Nicolas Girerd, MD, PhDa,
- John Gregson, PhDc,
- Ichraq Latar, MSca,
- Abhinav Sharma, MDd,e,
- Marc A. Pfeffer, MD, PhDf,
- John J.V. McMurray, MD, PhDg,
- Azmil H. Abdul-Rahim, MD, MSch,
- Bertram Pitt, MD, PhDi,
- Kenneth Dickstein, MD, PhDj,
- Patrick Rossignol, MD, PhDa,
- Faiez Zannad, MD, PhDa,∗ (, )
- for the High-Risk Myocardial Infarction Database Initiative
- aNational Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative–Cardiovascular and Renal Clinical Trialists, Nancy, France
- bDepartment of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
- cDepartment of Biostatistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
- dDuke Clinical Research Institute, Duke University, Durham, North Carolina
- eMazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- fDivision of Cardiovascular Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- gBHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
- hInstitute of Neuroscience and Psychology, University of Glasgow, Glasgow, Scotland, United Kingdom
- iDepartment of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
- jDepartment of Cardiology, University of Bergan, Stavanger University Hospital, Stavanger, Norway
- ↵∗Address for correspondence:
Dr. Faiez Zannad, Centre d’Investigations Cliniques-INSERM CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy, France.
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.
Dr. Ferreira has received board membership fees from Novartis; has received speaker fees from Roche; and is a co-founder of CardioRenal. Dr. Girerd has received board membership fees from Novartis; and has received speaker honoraria from Servier. Dr. Rossignol has received board membership fees from CTMA, CVRx, Fresenius Medical Care, Novartis, Relypsa, Vifor Fresenius Medical Renal Pharma, and Stealth Peptides. Dr. Sharma has received grant support from Takeda, Bayer, Roche Diagnostics, and Bristol-Myers Squibb-Pfizer. Dr. Pfeffer has received research grant support from Novartis; has been a consultant for AstraZeneca, Bayer, Boehringer Ingelheim, DalCor, Genzyme, Gilead, GlaxoSmithKline, Janssen, Lilly, Novartis, Novo Nordisk, Relypsa, Sanofi, Teva, and Thrasos; has received stock options from DalCor; and has received a share, which has been irrevocably assigned to charity, of a patent awarded to Brigham & Women’s Hospital and licensed by Novartis. Dr. Pitt has been a consultant for Bayer, AstraZeneca, Sanofi, Relypsa, Vifor, scPharmaceuticals, Stealth Peptides, Tricida, Sarfez Pharmaceuticals, and KDP Pharmaceuticals; and has received stock options from Relypsa and scPharmaceuticals. Dr. Zannad has received fees for serving on the board of Boston Scientific; has received consulting fees from Novartis, Takeda, AstraZeneca, Boehringer Ingelheim, GE Healthcare, Relypsa, Servier, Boston Scientific, Bayer, Johnson & Johnson, and Resmed; has received speaker fees from Pfizer and AstraZeneca; has been Janssen steering committee chair; and is a co-founder of CardioRenal. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 27, 2017.
- Revision received December 5, 2017.
- Accepted December 6, 2017.
- 2018 American College of Cardiology Foundation
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