Are there differences on prognosis among patients with previous ischemic heart disease versus cerebrovascular disease admitted with acute coronary syndrome?

Background: It is known that patients with previous vascular disease (PVD) have a poorer outcome than those without these previous conditions, and prognosis worsens as the number of affected vascular beds increases. Aim: To evaluate if there are differences in in-hospital and 6-month mortality among patients admitted with acute coronary syndromes with previous ischemic heart disease (IHD) versus cerebrovascular disease (CVD). Methods: We analysed 4871 patients (pts) admitted consecutively in our coronary care unit with a diagnosis of acute coronary syndrome and included in a prospective registry, from January 2002 to October 2013. Patients were divided in three groups: group 1 - pts without PVD, n=3718, 76,3%); group 2 – pts with previous IHD (n=825, 16.9%); group 3 - pts with previous CVD (n=257, 5.3%). We excluded pts with previous IHD plus CVD (n=71, 1.5%). For each group we compared clinical and laboratory features and adverse events. Primary endpoint was the occurrence of death at 6 months; follow-up was completed in 98% of patients. Results: The group with previous CVD were older (63±13 vs 67±12 vs 71±11; p<0.001), had higher proportion of women (25% vs 21.9% vs 32.3%; p<0.001) and hypertension (58% vs 73.1% vs 83.7%; p<0.001). Patients with previous IHD had more often body mass index >25kg/m2 (47.1% vs 52.5% vs 50.8%; p=0.016), dyslipidaemia (46% vs 69.3% vs 52.1%; p<0.001), diabetes (23.5% vs 38.8% vs 36.6%; p<0.001). They also were taking more often aspirin (11.6% vs 75% vs 35.8%; p<0.001) and statin (21.6% vs 70.5% vs 37.4%; p<0.001). Patients without PVD had more frequently history of smoking (29.5% vs 19.0% vs 12.8%; p<0.001) and absence of risk factors (8.7% vs 4.0% vs 3.9%; p<0.001). On admission, those with previous CVD presented more often with Killip >1 (19.6 % vs 29.6% vs 34.2%; p<0.001), anaemia (19.8% vs 28.6% vs 33.9%; p<0.001) and renal insufficiency (eGFR <60 ml/min) (19.2% vs 31% vs 40.9%; p<0,001). Patients with previous IHD presented more severe coronary artery disease (left main coronary artery or three vessels) (11.7% vs 22.2% vs 16.7%; p<0.001) and higher prevalence of left ventricular dysfunction (56.2% vs 61.8% vs 58.4%; p=0.034). ST-segment myocardial infarction was more prevalent in patients without PVD (54.5% vs 25.6% vs 51%; p<0.001) on the other hand myocardial infarction without ST-elevation was more frequent in patients with previous IHD (41.2% vs 65% vs 45.5%; p<0.001). In-hospital (4.5% vs 4.7% vs 7.0%; p<0.001) and 6-month mortality (8.7% vs. 10.6% vs. 16.5%; p<0.001) were higher in patients with previous CVD. In multivariate analysis and after adjusting for different baseline characteristics, patients with previous CVD had higher risk of 6-month mortality compared to those without PVD [OR 1.67, 95% CI (1.06-2.63), p=0.026].  Conclusion: Patients with previous vascular disease had higher prevalence of risk factors. Previous cerebrovascular disease remained as a strong predictor of 6-month mortality in patients admitted with acute coronary syndrome.