To investigate the clinical features and incidence of malignant neoplasia during 17 years of follow-up in an unselected sample of patients with acute coronary syndrome (ACS).
The Adria, Bassano, ...Conegliano, and Padova Hospital-4 Study on Heart Disease is an ongoing, prospective study of an unbiased population of patients with ACS. Baseline clinical and laboratory data were obtained during the first 7 days of hospitalization at three different intensive coronary care units. The current study included data from 589 patients with ACS.
At enrollment, 19 patients had confirmed neoplasia. During follow-up, 99 additional patients developed malignant neoplastic disease. The incidence rate was 17.8 cases per 1000 person-years, which was about three times higher than that observed in the general population. Patients had a shorter duration of neoplasia when they developed it after enrollment compared with those with preexisting neoplasia hazard ratio = 2.0 (1.5-2.6), P = 0.001. Patients with neoplasia who died during follow-up had an earlier onset of neoplasia hazard ratio = 1.8 (1.1-2.9), P = 0.01 and shorter duration than survivors hazard ratio = 4.1 (2.4-7.0), P < 0.0001. The estimated time to diagnosis of neoplasia indicated elderly patients had a significantly higher risk than younger people during the 17 years of follow-up. After the onset of neoplasia, survival time declined more sharply in the elderly than younger people.
The long-term prospective study showed that patients with ACS have a higher incidence of malignancy than the general population. Those who develop neoplasm after being diagnosed with ACS have a worse prognosis than patients with a preexisting neoplasia.
Emerging evidence suggests that patients with coronary artery disease carry an increased risk of developing malignancy, with deleterious effects on long-term prognosis. Our aim was to ascertain ...whether baseline plasma lipid levels during acute coronary syndrome (ACS) are associated with malignancy in long-term.
This study included 589 patients admitted with ACS to three centers and discharged alive. Plasma lipid levels were assessed on the first morning after admission. Patients were followed for 17 years or until death.
Five hundred seventy-one patients were free from malignancy at enrollment, of them 99 (17.3%) developed the disease during follow-up and 75 (13.1%) died due to it. Compared to patients without malignancy, those with malignancy showed lower plasma levels of total cholesterol (TC), low-density lipoprotein (LDL), and triglycerides (TG). The groups showed similar statin use rates at any time in follow-up. The incidence rate of neoplasia and neoplastic mortality was higher in patients with baseline TC or LDL values ≤ median; they showed 85 and 72% increased incidence rate of developing malignancy and 133 and 122% increased incidence rate of neoplastic death respectively. No differences were observed relative to HDL and TG levels. In survival analysis using Cox regression with parsimonious models, patients with baseline TC or LDL values > median, respectively, showed risks of 0.6(95% CI 0.4-0.9; p = 0.01) and 0.6(95%CI 0.4-0.9; p = 0.02) for malignancy onset, and 0.5(95% CI 0.3-0.8; p = 0.005) and 0.5(95% CI 0.3-0.8; p = 0.004) for neoplastic death. Similar results were obtained using competitive risk analysis with parsimonious models.
This long-term prospective study of an unselected real-world patient sample showed that neoplasia onset and mortality are independently associated with low plasma TC and LDL levels at admission for ACS.
Aims
A higher risk of cancer among patients with heart failure (HF) has been suggested in recent community‐based studies. This study aimed to investigate the impact of HF during hospitalization with ...acute coronary syndrome (ACS) on the long‐term cancer risk.
Methods and results
The study included 572 patients admitted with ACS to three Italian hospitals, discharged cancer‐free, and prospectively followed for 24 years or until death. All but three patients completed the follow‐up, which represented 6440 person‐years (mean age: 66 ± 12 years; 70% males). Baseline HF was diagnosed in 192 (34%) patients. A total of 129 (23%) patients developed cancer (103 without HF and 26 with HF), and 107 (19%) patients died due to it (81 without HF and 26 with HF). The incidence rates for cancer onset and cancer death were not different according to HF status. Cox regression analysis revealed no association between HF or left ventricular ejection fraction (LVEF) and cancer risk. In addition, no difference in cancer risk was observed among patients with HF with preserved ejection fraction, HF with mildly reduced ejection fraction, and HF with reduced ejection fraction. In competing risk regression analysis, the risk of cancer onset associated with HF was sub‐hazard ratio (SHR) 0.47 95% confidence interval (CI): 0.30–0.72; P = 0.001 and SHR 1.02 (95% CI: 1.01–1.04; P = 0.002) with LVEF. Results were the same in the adjusted model. Yet the fully adjusted model showed an attenuated association between cancer death and HF (SHR: 0.63; 95% CI: 0.37–1.05; P = 0.08) and LVEF (SHR: 1.02; 95% CI: 0.99–1.06; P = 0.08). Consistent results were obtained after using propensity score matching analysis that created 192 pairs. A negative interaction between age and HF and a positive interaction between age and LVEF for cancer risk have also been found.
Conclusions
An inverse association between baseline HF and long‐term cancer risk has been observed among the ABC Study on heart disease patients who were followed for 24 years after ACS.
An increased risk of cancer death has been demonstrated for patients diagnosed with acute coronary syndrome (ACS). We are investigating possible geographic risk disparities.
This prospective study ...included 541 ACS patients who were admitted to hospitals and discharged alive in three provinces of Italy's Veneto region. The patients were classified as residing in urban or rural areas in each province.
With 3 exceptions, all patients completed the 22-year follow-up or were followed until death. Urban (46%) and rural (54%) residents shared most of their baseline demographic and clinical characteristics. Pre-existing malignancy was noted in 15 patients, whereas 106 patients developed cancer during the follow-up period, which represented 6232 person-years. No difference in the cancer death risk was found between the urban and rural areas or between southern and northern provinces (hazard ratio HR 1.1; 95% confidence interval CI 0.7-1.7;
= 0.59 and HR 1.1; 95% CI 0.9-1.4;
= 0.29, respectively) according to the unadjusted Cox regression analysis. Geographic areas, however, showed a strong positive interaction, with risk increasing from the urban to rural areas from southern to northern provinces (HR 1.9; 95% CI 1.1-3.0;
= 0.01). The fully adjusted Cox regression and Fine-Gray competing risk regression models provided similar results. Interestingly, these results persisted, and even strengthened, after exclusion of the 22 patients who developed malignancy and survived to the end of follow-up. We did not observe an urban/rural difference in non-neoplastic death risk or a significant interaction between the geographic areas.
Our analysis reveals that the cancer death risk among unselected ACS patients in Italy's Veneto region significantly differs by geography. The northern rural area has the highest risk. These results highlight the importance of implementing a preventive policy based on area-specific knowledge.
Increased cancer risk has been reported in patients with acute coronary syndrome (ACS).
To investigate geographic differences in risk malignancy long after ACS.
We enrolled 586 ACS patients admitted ...to hospitals in three provinces in the Veneto region of Italy in this prospective study. Patient's residency was classified into three urban and three nearby rural areas.
All (except for 3) patients completed the follow-up (22 years or death) and 54 % were living in rural areas. Sixteen patients had pre-existing malignancy, and 106 developed the disease during follow-up. Cancer prevalence was 17 % and 24 % (p = 0.05) and incidence of malignancy was 16 and 21/1000 person-years for urban and rural areas, respectively. In unadjusted logistic regression analysis, cancer risk increased from urban to rural areas (odds ratio OR 3.4;95 % confidence interval CI 1.7-7.1; p = 0.001), with little change from north to south provinces (OR 1.5;95 % CI 1.0-2.2; p = 0.06). Yet, we found a strong positive interaction between urban-rural areas and provinces (OR 2.1;95 % CI 1.2-3.5; p = 0.003). These results kept true in the fully adjusted model. Unadjusted Cox regression analysis revealed increasing hazards ratios (HRs) for malignancy onset from urban to rural areas (HR 3.0;95 % CI 1.5-6.2; p = 0.02), but not among provinces (HR 1.3;95 % CI 1.0-2.0; p = 0.14). Also, we found a strong positive interaction between geographic areas (HR 2.1;95 % CI 1.3-3.5; p = 0.002), even with a fully adjusted model.
The results in unselected real-world patients demonstrate a significant geographic difference in malignancy risk in ACS patients, with the highest risk in the north-rural area.
The long-term event-free survival (EFS) after acute myocardial infarction (AMI) is largely uninvestigated. We analyzed noninvasive clinical variables in association with long-term EFS after AMI. The ...present prospective study included 504 consecutive patients with AMI at 3 hospitals from 1995 to 1998 (Adria, Bassano, Conegliano, and Padova Hospitals ABC study). Thirty-seven variables were examined, including demographics, cardiovascular risk factors, in-hospital characteristics, and blood components. The end point was 10-year EFS. Logistic and Cox regression models were used to identify the predictive factors. We compared 3 predictive models according to the goodness of fit and C-statistic analyses. At enrollment, the median age was 67 years (interquartile range 58 to 75), 29% were women, 38% had Killip class >1, and the median left ventricular ejection fraction was 51% (interquartile range 43% to 60%). The 10-year EFS rate was 19%. Both logistic and Cox analyses identified independent predictors, including young age (hazard ratio 1.2, 95% confidence interval 1.1 to 1.3, p = 0.0006), no history of angina (hazard ratio 1.4, 95% confidence interval 1.1 to 1.8, p = 0.009), no previous myocardial infarction (hazard ratio 1.4, 95% confidence interval 1.1 to 1.7, p = 0.01), high estimated glomerular filtration rate (hazard ratio 0.8, 95% confidence interval 0.7 to 0.9, p = 0.001), low albumin/creatinine excretion ratio (hazard ratio 1.2, 95% confidence interval 1.1 to 1.3, p <0.0001), and high left ventricular ejection fraction (hazard ratio 0.8, 95% confidence interval 0.7 to 0.9, p = 0.006). These variables had greater predictive power and improved the predictive power of 2 other models, including Framingham cardiovascular risk factors and the recognized predictors of acute heart damage. In conclusion, 10-year EFS was strongly associated with 4 factors (ABC model) typically neglected in studies of AMI survival, including estimated glomerular filtration rate, albumin/creatinine excretion ratio, a history of angina, and previous myocardial infarction. This model had greater predictive power and improved the power of 2 other models using traditional cardiovascular risk factors and indicators of heart damage during AMI.
Background Albumin excretion rate has been found to be associated with increased risk of mortality in several clinical settings. We assessed the relationship between urinary albumin and 7-year ...mortality in a cohort of patients with acute myocardial infarction (AMI). Methods In this prospective study, we examined 505 white patients admitted with AMI to the intensive care unit of 3 hospitals. Main end points were nonearly all-cause and cardiovascular (CV) mortality. Albumin-to-creatinine ratio (ACR) was measured by radioimmunoassay on the first, third, and seventh days after admission. Risk estimates were made using Cox proportional-hazard model and relative odds. Forty patients (7.9%) died early inhospital, and 175 (34.7%) died during the rest of the follow-up (nonearly mortality). Results The ACR measured on the third day predicted the occurrence of 7-year nonearly all-cause and CV mortality. Hazard ratios for ACR ≥0.97 mg/mmol were 3.0 (95% confidence limit 2.2-4.1), P < .0001, for nonearly all-cause mortality and 3.5 (95% confidence limit 2.5-5.0), P < .0001, for CV mortality. Correspondent fully adjusted hazard ratios were 1.9 (95% CI 1.4-2.6), P < .0001, and 2.2 (95% CI 1.5-3.2), P < .0001, respectively. By adding ACR to the 18-variable predictive model, ACR improved significantly both the goodness of fitting of the model for nonearly all-cause ( P < .0001) and CV mortality ( P < .0001) and the C-statistic value ( P < .0001 and P = .002 for nonearly all-cause and CV mortality, respectively). Similar results were obtained for ACR measured on the first day or the seventh day. Conclusions An early increase of urinary albumin in AMI is a strong independent predictor of long-term adverse clinical outcome. The ACR improved clinical prediction over and above baseline traditional multivariable risk models.
Microalbuminuria is associated with adverse outcomes in acute coronary syndrome (ACS) patients.
To evaluate the very long-term association between Microalbuminuria and the overall mortality and ...causes of death in this clinical setting, we prospectively studied 579 unselected ACS patients admitted to three hospitals. The baseline albumin-to-creatinine ratio (ACR) was measured on days 1, 3, and 7 in 24-h urine samples. Patients were followed for 22 years or until death.
Virtually all patients completed follow-up; 449(78%) had died: 41% due to non-sudden cardiac death (non-SCD), 19% sudden cardiac death (SCD), 40% due to non-cardiac (non-CD) death.
Using unadjusted Cox regression analysis, ACR was a significant predictor of all-cause mortality (hazard ratio HR 1.26;95%confidence interval CI 1.22–1.31; p˂0.0001) and the three causes of death (HR 1.40;95%CI 1.32–1.48; p˂0.0001), (HR 1.22;95%CI 1.12–1.32; p˂0.0001) and (HR 1.16;95%CI 1.09–1.23; p˂0.0001) for non-SCD, SCD and non-CD respectively.
Using a fully adjusted model, ACR was a significant independent predictor of all-cause mortality (HR 1.12; 95%CI 1.08–1.16; p˂0.0001) and only non-SCD (HR 1.21; 95%CI 1.14–1.29; p˂0.0001).
There was a positive interaction between ACR level and history of AMI (HR 1.15; 95%CI 1.03–1.29; p = 0.01) and the presence of heart failure at admission (HR 1.11; 95%CI 1.01–1.24; p = 0.04), and negative interaction with higher than median LVEF (HR 0.89; 95%CI 0.80–0.99; p = 0.03) for all-cause mortality at the multivariable level.
Based on the present analysis, baseline urinary albumin excretion during ACS is a strong independent predictor of the very long-term mortality risk, chiefly due to non-sudden cardiac death.
Nelson-Aalen cumulative hazard estimates for all-cause and causes of death during 22 years of follow-up according to baseline ACR level.
ACR= Urinary albumin-to-creatinine excretion ratio (mg/g); non-SCD= non-sudden cardiac death; non-CD= non-cardiac death; SCD= sudden cardiac death.
* Values from the Cox regression analysis using a model adjusted for baseline age, gender, smoking, diabetes mellitus, hypertension, history of infarction, presence of heart failure at admission, and plasma total cholesterol level Display omitted
•Microalbuminuria is associated with all-cause mortality in patients with ACS.•Little is known about its association with different causes of death.•In this study, ACS patients were enrolled and prospectively followed for 22 years.•Baseline microalbuminuria is a strong independent predictor only of non-SCD.•An independent interaction was found between ACR and indicators of heart failure.
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