Patients with autoimmune diseases are at higher risk of complications after a heart attack

In a recent study published in the Journal of the American Heart Associationresearchers evaluated the mid-term and management outcomes of acute myocardial infarction (AMI) in patients with immune-mediated inflammatory rheumatic diseases (IMID).

AMI has been associated with a cascade of local and distant immune response activation. Additionally, studies have reported a positive association between rheumatic IMIDs and the risk of cardiovascular disorders such as ACS (acute coronary syndrome). However, the long-term prognosis of ACS in patients with rheumatic IMID has not been well characterized.

​​​​​​​Study: results after acute coronary syndrome in patients with and without immune-mediated rheumatic inflammatory diseases. Image Credit: M. Dasenna / Shutterstock

About the study

The present study evaluated the outcomes of AMIs in patients with rheumatic IMID.

The study included 1,654,862 Medicare beneficiaries with a prevalence of 3.6% rheumatoid IMID, the most common of which was rheumatoid arthritis, followed by systemic lupus erythematosus, and hospitalized between January 2014 and December 2019. The results of the patients with concurrent rheumatic AMI and IMID such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), dermatomyositis, psoriasis or systemic sclerosis were compared to those among 1:3 (IMID group: controls) propensity score (PSM) matched control patients without rheumatic IMIDs.

Data were obtained for race, gender, age, and patient enrollment dates, and PSM was performed to adjust for variables such as gender, race, age, MI with ST-segment elevation (STEMI), comorbidities and non-STEMI (NSTEMI). The team excluded patients younger than 65 and those who had not been enrolled in fee-for-service for ≥ 1 year prior to index IM admission.

All-cause mortality was the primary endpoint of the study. The study’s secondary endpoints were in-hospital ARI (acute kidney injury), major bleeding, death at 30 days and at one year, time to hospital readmission due to MI, stroke, heart failure and coronary revascularization needs [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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