Prior peripheral arterial disease and cerebrovascular disease are independent predictors of adverse outcome in patients with acute coronary syndromes: are we doing enough? Results from the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis In Myocardial Infarction (OPUS-TIMI) 16 study.
BACKGROUND
Cerebrovascular accidents (CVAs), transient ischemic attacks (TIAs), and peripheral arterial disease (PAD) frequently coexist with coronary artery disease (CAD) and were previously reported to adversely affect the prognosis of patients with chronic CAD.


METHODS
We examined the effect of prior CVA/TIA or PAD (extra-cardiac vascular disease [EVD]) on the outcome of 10,281 patients with acute coronary syndromes enrolled in the Orbofiban in Patients with Unstable Coronary Syndromes-Thrombolysis in Myocardial Infarction (OPUS-TIMI) 16 trial of the oral glycoprotein IIb/IIIa antagonist orbofiban plus aspirin versus aspirin alone. We evaluated mortality, recurrent cardiac events, and stroke and used multivariate analysis to control for differences in baseline characteristics.


RESULTS
Patients with EVD were older, had more coronary risk factors, had a history of CAD, and received more intensive medical treatment at baseline. The acute event in these patients was more often unstable angina pectoris and less commonly Q-wave myocardial infarction. With coronary angiography, patients with prior EVD more often had multivessel disease. During the 10 months of follow-up, the presence of EVD was predictive of an increased hazard of death, reinfarction, recurrent ischemia, stroke, and a composite of these events. Despite the increased severity of the CAD and increased risk of events, patients with EVD were treated less frequently with beta-blockers and more frequently with calcium blockers. Despite patients with EVD having a 45% higher incidence of hypercholesterolemia, lipid-lowering agents were prescribed in a similar percentage of patients as patients without EVD.


CONCLUSIONS
In patients with acute coronary syndromes, the presence of prior CVA, TIA, or PAD is associated with more extensive CAD and worse outcome. These patients appear to receive less aggressive treatment, which may explain, at least in part, their worse outcome.
Cotter
Gad
G
Cardiology Institutes of Assaf-Harofeh Medical Center, Zerifin, Israel. cotterg@hotmail.com
Cannon
Christopher P
CP
McCabe
Carolyn H
CH
Michowitz
Yoav
Y
Kaluski
Edo
E
Charlesworth
Andrew
A
Milo
Olga
O
Bentley
Jane
J
Blatt
Alex
A
Krakover
Rikardo
R
Zimlichman
Reuven
R
Reisin
Leonardo
L
Marmor
Alon
A
Lewis
Basil
B
Vered
Zvi
Z
Caspi
Avi
A
Braunwald
Eugene
E
D000368:Aged; D000409:Alanine / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use; D002561:Cerebrovascular Disorders / Q000150:complications*; D003327:Coronary Disease / Q000150:complications / Q000188:drug therapy*; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015999:Multivariate Analysis; D016491:Peripheral Vascular Diseases / Q000150:complications*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011446:Prospective Studies; D011759:Pyrrolidines / Q000627:therapeutic use*; D012044:Regression Analysis; D012307:Risk Factors; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011759:Pyrrolidines; C120234:orbofiban; D000409:Alanine; D001241:Aspirin