Beta-blockers for post-acute coronary syndrome mid-range ejection fraction: a nationwide retrospective study.

BACKGROUND: Patients with mid-range ejection fraction (40-49%) are in focus due to the newly defined entity of heart failure with mid-range ejection fraction. Acute coronary syndromes are a major aetiology for heart failure with mid-range ejection fraction. We aim to evaluate which therapeutic decisions are associated with inhospital survival benefit in post-acute coronary syndrome patients categorised according to the ejection fraction. METHODS AND RESULTS: The authors analysed a cohort of a multicentre national registry enrolling acute coronary syndrome patients between 2010 and 2016, classified according to their ejection fraction before hospital discharge. Patients with previously known heart failure or with no ejection fraction evaluation were excluded. A total of 9429 patients were included and categorised in three groups: (a) ejection fraction of 50% or greater (n=6113, 65%); (b) ejection fraction of 40-49% (n=1926, 20%); and (c) ejection fraction less than 40% (n=1390, 15%). The primary endpoint was inhospital mortality. To eliminate confounding factors, a multivariate logistic regression analysis was conducted, including acute coronary syndrome type, baseline characteristics, pharmacological treatment, clinical data, laboratory data and coronary anatomy when known. The overall inhospital mortality was 2.8% (n=263): 0.9% (n=53) in group 1, 2.4% (n=37) in group 2 and 11.4% (n=159) in group 3. After multivariate analysis, an invasive strategy had a positive impact in all groups, inhospital beta-blocker administration had a positive impact for groups 2 and 3, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and spironolactone had a positive impact on group 3. CONCLUSION: Post-acute coronary syndrome mid-range ejection fraction patients represent an intermediate risk group in which beta-blocker administration was associated with inhospital survival benefit. An invasive strategy was a survival predictor for all groups, regardless of ejection fraction category.

Prior exposure to aspirin in acute coronary syndrome patients: a cardiovascular risk marker or a predictor of adverse outcome? A contemporary data of a national registry.

Despite the known protective cardiovascular effect of aspirin, former studies identified its prior exposure to an acute coronary syndrome (ACS) as an independent risk factor for adverse events. However, those studies did not reflect contemporary approaches. In the current study, we determine whether patients exposed to aspirin before an ACS have a worse cardiovascular risk profile and if it predicts higher risk of recurrent cardiovascular events or mortality. A cohort of patients enrolled in a national registry of ACS was analyzed according to prior exposure to aspirin. A propensity score standardized patients according to baseline comorbidities. Multivariable COX regression analysis was performed in unmatched and matched populations for a primary endpoint (composite of all-cause mortality and/or cardiovascular rehospitalization) and two secondary endpoints (all-cause mortality and cardiovascular rehospitalization, separately) at 1-year follow-up. Among 5533 ACS patients, 1763 were previously exposed to aspirin. They were older and had more comorbidities; contemporary approaches, both coronary angiography and percutaneous coronary angioplasty were less likely to be performed. Before matching the population, prior exposure to aspirin was an independent predictor of primary composite endpoint (p = 0.002) and cardiovascular rehospitalization as the secondary endpoint (p = 0.001). There were no statistically significant differences between both groups in the multivariable model for the primary or secondary endpoints after matching. Previous exposure to aspirin identified ACS patients with worse baseline characteristics, establishing its role as a cardiovascular risk marker. However, our data do not support including aspirin pretreatment in risk stratification scores as an adverse prognostic variable.