Investigators believe that coronary intervention, intensified medical therapy, and an aggressive risk factor optimization approach should be available to patients with rheumatic disease presenting with myocardial infarction whenever possible.
Patients with rheumatic immune mediated inflammatory diseases (IMIDs) who experience myocardial infarction (MI) had a higher risk of recurrent MI, heart failure, mortality, and coronary reintervention during a follow-up period when compared with patients without autoimmune disease. This patient population was also less likely to receive common procedures to restore blood flow after MI due to an increased risk of complications, according to a study published in Journal of the American Heart Association.1
“Patients with rheumatic IMIDs usually suffer from higher prevalence of traditional risk factors such as hypertension and diabetes with systemic lupus erythematosus (SLE) and smoking with rheumatoid arthritis (RA),” investigators explained. “However, the significant increase in the risk of cardiovascular disease cannot be solely explained by these traditional risk factors. The state of chronic systemic inflammation, with its resultant lipid metabolism dysregulation, as well as autoantibodies-associated increased thrombotic risk in those patients, are likely to play a significant role.”
Medicare beneficiaries diagnosed with MI between January 2014 to December 2019 were included in the analysis. Outcomes of patients with IMIDs, including RA, SLE, and psoriasis (PsO), were matched 1:3 with non-IMID controls for exact age, sex, race, ST-segment-elevation MI (STEMI), and non-ST-segment-elevation MI (NSTEMI) variables. Medicare Beneficiary Summary Files were utilized to extract demographic information. A 1-year look-back period was used to identify comorbidities based on ICD codes and any comorbidities were evaluated using a greedy approach. The primary outcome was all-cause mortality at the longest follow-up available.
Of the 1,654,862 patients, 3.6% (n = 60,072) were diagnosed with a rheumatic IMID, with the most common being RA and SLE. Those with an autoimmune diagnosis tended to be younger, were more likely to be women, and more likely to present with NSTEMI. These patients were also less likely to undergo coronary artery bypass grafting, percutaneous coronary intervention, or coronary angiography.
After propensity-score matching, with a median follow-up period of 24 months (interquartile range 9-45 months), mortality was significantly higher in patients with IMIDs when compared with the control group (22.5 vs 19.1 deaths per 100 person-year adjusted hazard ratio [HR] 1.15 [95% CI, 1.14–1.17], P<0.001). Further, risk of coronary reintervention (HR, 1.06 [95% CI, 1.01–1.13]), recurrent MI (HR, 1.08 [95% CI 1.06–1.11]), and heart failure (HR, 1.12 [95% CI 1.09–1.14]) were also higher in those with rheumatic disease when compared with controls.
The study was limited by obtaining Medicare data via an administrative database, which may be subject to documentation errors. Further, variables such as disease duration, disease activity, damage indices, laboratory information, imaging data, and medication information was not available. Lastly, as the analysis focused on Medicare patients (aged 65 years or older), results are not generalizable to younger patients who may be more affected by the increased risk of premature coronary artery disease.
Investigators believe that coronary intervention, intensified medical therapy, and an aggressive risk factor optimization approach should be available to patients with IMIDs and MI whenever possible.
“Future research is needed on medications and interventions that might reduce the heightened risk for poor outcomes in heart attack patients with autoimmune disease, such as investigating whether different immune modulators and immune-suppressant therapies used to control and treat the autoimmune disease have any impact in improving post-heart-attack outcomes,” lead investigator Heba Wassif, MD, MPH, concluded.
Wassif H, Saad M, Desai R, et al. Outcomes following acute coronary syndrome in patients with and without rheumatic immune-mediated inflammatory diseases. doi:10.1161/JAHA.122.026411