心臓発作後の合併症のリスクが高い自己免疫疾患患者

Study: Outcomes Following Acute Coronary Syndrome in Patients With and Without Rheumatic Immune‐Mediated Inflammatory Diseases. ​​​​​​​Image Credit: Mr Dasenna / Shutterstock


Journal of the American Heart Association に掲載された最近の研究では、研究者は、リウマチ性免疫介在性炎症性疾患 (IMID) 患者の急性心筋梗塞 (AMI) の中期および管理転帰を評価しました。

AMI は、ローカルおよびリモートの免疫応答活性化のカスケードに関連付けられています。 さらに、研究では、リウマチ性 IMID と ACS (急性冠症候群) などの心血管障害のリスクとの正の関連性が報告されています。 ただし、リウマチ性 IMID 患者における ACS の長期予後は十分に解明されていません。

研究:リウマチ性免疫介在性炎症性疾患のある患者とない患者における急性冠症候群後の転帰。 画像著作権: Dasenna 氏 / Shutterstock

研究について

本研究では、リウマチ IMID 患者の AMI 転帰を評価した。

この研究は、リウマチ性 IMID の有病率が 3.6% の 1,654,862 人のメディケア受益者で構成されており、最も一般的なのは関節リウマチで、全身性エリテマトーデスが続き、2014 年 1 月から 2019 年 12 月の間に入院しました。関節リウマチ (RA)、全身性エリテマトーデス (SLE)、皮膚筋炎、乾癬、または全身性硬化症を、リウマチ性 IMID を持たない 1:3 (IMID グループ: コントロール) の傾向スコア一致 (PSM) コントロール患者と比較したためです。

患者の人種、性別、年齢、および登録日に関するデータが取得され、性別、人種、年齢、ST 上昇 MI (STEMI)、併存疾患、および非 STEMI (NSTEMI) などの変数を調整するために PSM が実行されました。 )。 チームは、65 歳未満の患者、および指標 MI の入院前に 1 年以上有料サービスに登録されていない患者を除外しました。

全死因死亡率は、研究の主要な結果でした。 二次試験の結果は、院内 AKI(急性腎障害)、大出血、30 日および 1 年間の死亡、心筋梗塞による再入院期間、脳卒中、心不全(心不全)、および冠動脈血行再建術の必要性でした。 [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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