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INTRODUCTION — Survivors of a first, acute myocardial infarction (MI) face a substantial risk of further cardiovascular events, including death, recurrent myocardial infarction, heart failure, arrhythmias, angina, and stroke. Patients (and family members) often ask what their future holds; thus, information regarding prognosis after MI is necessary for patient care.
The outcomes discussed in this topic, such as mortality, are presented using pooled data. However, the prognosis may vary widely between individuals, according to the presence or absence of risk factors present before the MI. These risk factors are discussed elsewhere. (See "Risk factors for adverse outcomes after non-ST elevation acute coronary syndromes" and "Risk factors for adverse outcomes after ST-elevation myocardial infarction".)
The likelihood of subsequent events presented here are rough estimates. For most patients with MI, clinicians should risk stratify them using validated risk prediction models. This process is described in detail separately. (See "Risk stratification after acute ST-elevation myocardial infarction" and "Risk stratification after non-ST elevation acute coronary syndrome".)
The discussion of sudden cardiac death following MI is found elsewhere. (See "Incidence of and risk stratification for sudden cardiac death after acute myocardial infarction" and 'Adverse non-fatal outcomes' below.)
SHORT-TERM OUTCOMES — Reported outcomes, and in particular, mortality, will vary based on the population studied. While many of the reports come from randomized trials, we consider outcomes reported from registries to be a better gauge. Registries usually include broad populations whereas trial participation is often limited by inclusion/exclusion criteria.
Mortality — Across the broad spectrum of patients with acute myocardial infarction (MI), short-term (in-hospital or 30-day) mortality has been decreasing over the past 30 years, concomitantly with the increasing use of reperfusion strategies and proven preventative therapies such as beta blockers, aspirin, and statins [1-9]. (See "Selecting a reperfusion strategy for acute ST elevation myocardial infarction" and "Trials of conservative versus early invasive therapy in unstable angina and non-ST elevation myocardial infarction" and "Secondary prevention of cardiovascular disease".)
The current 30-day mortality after all acute coronary syndromes (ST-elevation myocardial infarction [STEMI], non-ST elevation myocardial infarction [NSTEMI], and unstable angina) is probably in the 2 to 3 percent range, but likely around 5 percent if patients with unstable angina are not included . (See "Overview of the acute management of ST elevation myocardial infarction".)
In a report that evaluated the interval 1987 to 2002, the 28-day case fatality fell from 5.3 to 3.8 percent . A similar trend was noted in an analysis of data on 2.5 million patients from the National Registry of Myocardial Infarction in which in-hospital mortality after an acute MI declined from 10.4 percent in 1994 to 6.3 percent in 2006 .
STEMI — The 30-day mortality rate of patients with ST-elevation myocardial infarction (STEMI) is between 2.5 and 10 percent in more recent reports [10,12-15].
Both in-hospital and 30-day mortality rates after STEMI have been lower in clinical trials compared to registries and reports in patients not in clinical trials. This has been explained by enrollment of a lower risk population and better adherence to proven therapies in the former. Among patients with STEMI enrolled in trials, approximate in-hospital or 30-day mortality rates were 13 percent with medical therapy alone, 6 to 7 percent with optimal fibrinolytic therapy [16,17], and as low as 3 to 5 percent with primary percutaneous coronary intervention (PCI) when performed within two hours of chest pain onset [14,18,19]. (See "Characteristics of fibrinolytic (thrombolytic) agents and clinical trials in acute ST elevation myocardial infarction" and "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'Time from hospital arrival (door-to-balloon time)'.)
Somewhat higher in-hospital and 30-day mortality rates after STEMI have been described in patients not enrolled in clinical trials and cared for during a similar time period. The reported in-hospital mortality has been reported between 7 and 9.7 percent and the 30-day mortality between 11.1 and 14 percent for patients [15,20,21]. A number of factors could contribute to this difference, including patient selection, less frequent use of appropriate therapies, and data collection before trials supporting the value of primary PCI [15,20-22].
More contemporary reports of patients not enrolled in trials have documented a continued decline in mortality in STEMI patients [12,13,23]. For example, outcomes were presented in a 2012 report of 6707 STEMI patients in four French nationwide registries conducted five years apart (1995, 2000, 2005, and 2010) . The following findings were noted:
NSTEMI — Among patients with a non-ST elevation acute coronary syndrome (ACS), in-hospital or 30-day mortality has been about 2 percent in major clinical trials, lower than that seen in STEMI [25,26]. Although an early invasive strategy is now performed in most patients, because of reductions in recurrent MI or rehospitalization for an ACS, mortality rates in randomized trials were not significantly reduced in-hospital (or at six months) by this strategy [25,26]. (See "Trials of conservative versus early invasive therapy in unstable angina and non-ST elevation myocardial infarction".)
The following studies include the range of findings for patients not enrolled in randomized controlled clinical trials:
STEMI versus NSTEMI — Short-term mortality is lower in patients with NSTEMI (2 to 4 percent) compared to patients with STEMI (3 to 8 percent) treated with primary PCI within two hours of hospital arrival [10,18,19,21,25,26,30]. The American College of Cardiology National Cardiovascular Data Registry (NCDR) collects information on patients who undergo cardiac catheterization and percutaneous coronary intervention in the US . The risk-adjusted in-hospital mortality between 2007 and 2009 for the subset of acute MI patients who underwent PCI was about 6 percent for STEMI and about 4 percent for NSTEMI. For both types of MI, there were trends toward lower mortality with time.
Better short-term outcomes for patients with NSTEMI have also been noted in other studies (eg, in-hospital mortality 5 to 7 percent compared with 7.0 to 9.3 percent with STEMI in the GRACE and Euro Heart registries) [20,21,25].
Adverse non-fatal outcomes — Besides death, other patient-important outcomes include stroke, recurrent MI, heart failure, and major bleeding. In the GRACE registry of patients with non-ST elevation acute coronary syndromes (NSTEACS) discussed above, the rates of in-hospital heart failure or shock, MI, major bleeding, or stroke were 10, 2.4, 1.8, and 0.5 percent, respectively . In the HORIZONS AMI randomized trial, the rate of stroke was around 1 percent and the rate of reinfarction was about 2 percent at 30 days . (See "Anticoagulant therapy in acute ST elevation myocardial infarction", section on 'Bivalirudin'.)
Early rehospitalization — The rate of rehospitalization within 30 days after acute MI is reported to range between 17 and 25 percent [31,32]. In a single-community (Olmsted County, Minnesota, United States) study of 3010 patients who were hospitalized for a first-ever MI (31 percent STEMI) between 1987 and 2010, rehospitalization within 30 days occurred in about 19 percent . Of these, 30 percent were and 43 percent were not related to the incident event. Diabetes, chronic obstructive pulmonary disease, anemia, higher Killip class (table 1), longer length of stay during the index hospitalization, and a complication of angiography or reperfusion or revascularization were associated with increase rehospitalization risk.
− Similar to short-term outcomes, long-term mortality rates after myocardial infarction (MI) have declined significantly during the past 30 years due to reperfusion and preventative strategies. In an analysis of 23 published studies in which follow-up was completed prior to 1980, the death rate was about 28 percent at five years . A report had a five-year death rate of about 21 percent in patients treated between 1989 and 1993 .
In contrast to the short-term outcomes, which are worse with ST-elevation myocardial infarction (STEMI), long-term outcomes have been similar or worse with non-ST elevation myocardial infarction (NSTEMI) [2,25,36-40]. The largest direct comparison comes from the GUSTO-IIb trial performed in the early 1990s of 12,142 patients with STEMI, NSTEMI (using only CK-MB, not troponins, for diagnosis), or unstable angina . The mortality rate at 30 days was lower with NSTEMI than STEMI (3.8 versus 6.1 percent). In contrast, the mortality at one year was similar (8.8 for NSTEMI versus 9.6 percent for STEMI). However, outcomes from patients with NSTEMI managed more recently were lower in the ISAR REACT 4 trial, in which mortality at one year was about 4.4 percent. (See "Anticoagulant therapy in non-ST elevation acute coronary syndromes", section on 'Bivalirudin'.)
In a community-based observational study of almost 6000 first MIs over a 23-year period, patients with an NSTEMI (compared to those with STEMI) had higher two-year mortality (20 versus 11 percent) . Other registry reports suggest that, at one and two years, the cumulative mortality for NSTEMI exceeds that of STEMI patients. In the OPERA registry, cardiovascular outcomes were evaluated in 2151 consecutive patients (71 percent STEMI) with confirmed MI during 2002 and 2003 . The STEMI patients were treated with primary percutaneous coronary intervention (PCI) (71 percent) or fibrinolytic therapy (29 percent), while PCI was performed in 52 percent of NSTEMI patients. In-hospital mortality was not different for both groups (4.6 versus 4.3 percent), while the one-year post-discharge mortality was higher with NSTEMI (8.2 versus 5.0 percent). In a report for the Worcester (Massachusetts US) Heart Attack Study, the one-year post-discharge case fatality rates in 2005 for patients with STEMI and NSTEMI were 8.4 and 18.7 percent, respectively .
Further evidence suggesting worse long-term outcomes with NSTEMI comes from a comparison of two studies that evaluated outcomes separately. A French registry evaluated outcomes in 1645 patients with NSTEMI managed with an invasive strategy during 2005 and found that mortality at three years was approximately 20 percent, with about half the deaths due to cardiovascular causes . However, mortality at three years was around 6 to 7 percent in the HORIZONS AMI trial of patients with STEMI who underwent primary percutaneous coronary intervention . (See "Anticoagulant therapy in acute ST elevation myocardial infarction", section on 'Bivalirudin'.)
The similar or worse long-term prognosis in NSTEMI is in part related to more than a 50 percent prevalence of multivessel disease in affected patients and to a greater likelihood of residual ischemia [36,43,44], indicating that in these patients, a significant amount of myocardium often remains at risk.
Adverse non-fatal outcomes — While most patients are concerned about survival, many ask questions about other clinically important outcomes:
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