Pacienții cu boli autoimune prezintă un risc mai mare de complicații după un atac de cord


Într-un studiu recent publicat în Jurnalul Asociației Americane a Inimiicercetătorii au evaluat rezultatele pe termen mediu și ale managementului infarctului miocardic acut (IMA) la pacienții cu boli reumatice inflamatorii mediate imun (IMID).

IMA a fost asociat cu o cascadă de activare a răspunsului imun local și la distanță. În plus, studiile au raportat o asociere pozitivă între IMID reumatice și riscul de tulburări cardiovasculare, cum ar fi SCA (sindromul coronarian acut). Cu toate acestea, prognosticul pe termen lung al SCA la pacienții cu IMID reumatismal nu a fost bine caracterizat.

​​​​​Studiu: rezultate după sindromul coronarian acut la pacienții cu și fără boli inflamatorii reumatismale mediate imun. Credit imagine: M. Dasenna / Shutterstock

Despre studiu

Prezentul studiu a evaluat rezultatele IAM la pacienții cu IMID reumatismal.

Studiul a inclus 1.654.862 beneficiari Medicare cu o prevalență de 3,6% IMID reumatoidă, dintre care cea mai frecventă a fost poliartrita reumatoidă, urmată de lupus eritematos sistemic și internați în perioada ianuarie 2014 – decembrie 2019. Rezultatele pacienților cu IAM și IMID concomitent cum ar fi artrita reumatoidă (RA), lupusul eritematos sistemic (LES), dermatomiozita, psoriazisul sau scleroza sistemică au fost comparate cu cele dintre 1:3 (grup IMID: controale) cu scorul de propensiune (PSM) potriviți la pacienții de control fără IMID reumatice.

Au fost obținute date pentru rasă, sex, vârstă și datele de înscriere a pacienților, iar PSM a fost efectuat pentru a ajusta variabile precum sexul, rasa, vârsta, IM cu supradenivelare de segment ST (STEMI), comorbiditățile și non-STEMI (NSTEMI). Echipa a exclus pacienții cu vârsta mai mică de 65 de ani și pe cei care nu fuseseră înscriși în taxă pentru serviciu cu ≥ 1 an înainte de admiterea prin index IM.

Mortalitatea de orice cauză a fost obiectivul principal al studiului. Obiectivele secundare ale studiului au fost IRA în spital (leziune renală acută), sângerare majoră, deces la 30 de zile și la un an, timpul până la readmisia la spital din cauza IM, accident vascular cerebral, insuficiență cardiacă și nevoi de revascularizare coronariană. [PCI (percutaneous coronary intervention) or CABG (coronary artery bypass graft), and burden of readmission due to HF in the initial post-MI year (which was measured as the rate for every 100 individual-months).

A one-year look-back period was considered for ascertaining patient comorbidities based on the ICD (international classification of diseases) codes submitted in inpatient medical claims. Mortality data and readmissions data were available through August 2020 and December 2019, respectively. Regression modeling was used for the analysis, and the adjusted hazard ratios (HRs), odds ratios (OR), and relative risks (RR) were calculated. In addition, sensitivity analyses were performed with data adjustments for sex, race, age, and comorbid conditions without PSM, and evaluation of the study outcomes considering each rheumatic IMID separately.

Results

The final cohort after propensity score matching included 59 820 patients with rheumatic IMIDs versus 178,547 patients without. Rheumatic IMID was reported in 3.6% of patients, and the most commonly reported rheumatic IMIDs were RA and SLE, reported in 46,747 and 7,362 individuals, respectively. Psoriasis, systemic sclerosis, and dermatomyositis were reported in 3,098, 1,738, and 1,127 patients, respectively.

In comparison to non-rheumatic IMID patients, rheumatic IMID patients were lower aged (average age of 77 years vs. 78 years), with more likelihood of being female (67% vs. 44%), and with a greater prevalence of NSTEMI (77% vs. 75%) pulmonary hypertension, valvular diseases, anemia, and hypothyroidism.

Among NSTEMI patients, rates of CABG (7.7% vs. 11%), coronary angiography (46% vs. 52%), and PCI (32% vs. 34%) were lesser among rheumatic IMID patients vs. non-rheumatic IMID patients, respectively. Among STEMI patients, the rates of CABG (five percent vs. 6.4%), coronary angiography procedure (78% vs. 81%), and PCI (70% vs. 72%) were lesser among rheumatic IMID patients vs. non-rheumatic IMID patients, respectively.

Patients with rheumatic IMIDs were less likely to undergo coronary angiography, percutaneous coronary intervention, or coronary artery bypass grafting. After PSM and a two-year follow-up, risks for mortality irrespective of acute MI type; (HR 1.2), HF (HR 1.1), recurrent MI (HR 1.1), and coronary reintervention (HR 1.1) were higher among patients with rheumatic IMIDs.

The 30-day death risks were comparable among both the groups (12% vs. 11%), but the one-year death risk was greater among AMI patients with vs. without rheumatic IMIDs (29% vs. 27%, OR 1.2), respectively. In addition, the HF readmission burden at one-year post-index AMI year was significantly greater among AMI patients with rheumatic IMIDs vs. without rheumatic IMIDs (6.2 vs. 5.7 admissions for every 100 individual-month, RR 1.1), respectively. Among in-hospital AMI outcomes, the risks of major bleeding (4.6% vs. 4.9%) and AKI (25% vs. 26%) were lower among AMI patients with rheumatic IMIDs vs. without rheumatic IMIDs.

After the sensitivity analyses, the associations between AMI outcomes and rheumatic IMIDs were not significantly altered. All rheumatic IMIDs, except for psoriasis, were linked to more significant mortality risks and recurrent MI risks, whereas RA, systemic sclerosis, and SLE were linked to more significant HF risks. RA and SLE were associated with higher coronary reintervention requirement risk, whereas only SLE only was linked to greater stroke risk.

Overall, the study findings showed that patients with AMI and rheumatic IMIDs had increased risks of death, heart failure, recurrent MI, and coronary reintervention requirements in the long-term compared to patients without rheumatic IMIDs.

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