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Abstract
Objective Post-myocardial infarction (MI) care is crucial to preventing recurrent major adverse cardiovascular events (MACE), but can be complicated to personalise. A tool is needed that effectively stratifies risk of cardiovascular (CV) events 1–3 years after MI but is also clinically usable.
Methods Patients surviving ≥1 year after an index MI with ≥1 risk factor for recurrent MI (ie, age ≥65 years, prior MI, multivessel coronary disease, diabetes, glomerular filtration rate <60 mL/min/1.73 m2) were studied. Cox regression derived sex-specific Intermountain Major Adverse Cardiovascular Events (IMACE) risk scores for the composite of 1-year to 3-year MACE (CV death, MI or stroke). Derivation was performed in 70% of subjects (n=1342 women; 3047 men), with validation in the other 30% (n=576 women; 1290 men). Secondary validations were also performed.
Results In women, predictors of CV events were glucose, creatinine, haemoglobin, platelet count, red cell distribution width (RDW), age and B-type natriuretic peptide (BNP); among men, they were potassium, glucose, blood urea nitrogen, haematocrit, white blood cell count, RDW, mean platelet volume, age and BNP. In the primary validation, in women, IMACE ranged from 0 to 11 (maximum possible: 12) and had HR=1.44 per +1 score (95% CI 1.29 to 1.61; P<0.001); men had IMACE range 0–14 (maximum: 16) and HR=1.29 per +1 score (95% CI 1.20 to 1.38; P<0.001). IMACE ≥5 in women (≥6 in men) showed strikingly higher MACE risk.
Conclusions Sex-specific risk scores strongly stratified 1-year to 3-year post-MI MACE risk. IMACE is an inexpensive, dynamic, electronically delivered tool for evaluating and better managing post-MI patient care.
- clinical decision tool
- precision medicine
- learning healthcare system
- implementation science
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Footnotes
Contributors BDH, JBM and DLL designed the study. BDH, JBM, DB, GLH, NDK and TLB planned the execution of the study. BDH and TLB collected and prepared the data. BDH conducted statistical analyses. BDH, JBM, DB, GLH, NDK and DLL evaluated and interpreted the results. BDH and DLL drafted the manuscript, and JBM, DB, GLH, NDK, TLB and DLL revised the paper for important intellectual content.
Funding This work was supported by an unrestricted educational grant from AstraZeneca to BDH, JBM and DLL, and these Intermountain investigators had final authority over manuscript content.
Competing interests BDH is an inventor of IMRS and two readmission risk scores that are licensed to CareCentra for integration into their products. BDH is PI of grants funded by Intermountain Healthcare’s Foundry Innovation Program, the Intermountain Research and Medical Foundation, CareCentra, AstraZeneca and GlaxoSmithKline for the development and/or implementation of clinical risk scores. DB, GLH and NDK are employees of AstraZeneca.
Ethics approval This study was approved by the Intermountain Healthcare Institutional Review Board and was determined to be a minimal risk, general data-only study that posed minimal risk to subjects and for which a waiver of consent was provided.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement While the data used in this study are HIPAA-protected private information, with the execution of an appropriate institutional contractual agreement, the authors are pleased to collaborate with other scientists on further evaluations of the study data or the larger source data sets available through Intermountain Healthcare.