Prediction of one-year survival in high-risk patients with acute coronary syndromes: results from the SYNERGY trial.
BACKGROUND
Despite advances in pharmacologic therapy and invasive management strategies for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), these patients still suffer substantial morbidity and mortality.


OBJECTIVE
The objective of this study was to analyze independent predictors of 1-year mortality in patients with high-risk NSTE ACS.


METHODS
A total of 9,978 patients were assigned to receive enoxaparin or unfractionated heparin (UFH) in this prospective, randomized, open-label, international trial.


METHODS
Vital status at 1 year was collected. Univariable and multivariable predictors of 1-year mortality were identified. Three different multivariable regression models were constructed to identify: (1) predictors of 30-day mortality; (2) predictors of 1-year mortality; (3) predictors of 1-year mortality in 30-day survivors. The last model is the focus of this paper.


RESULTS
Overall, 9,922 (99.4%) of patients had 1-year follow-up. Of the 56 patients (37 UFH-assigned and 19 enoxaparin-assigned) without 1-year data, 11 patients were excluded because of withdrawal of consent, and 45 could not be located. One-year mortality was 7.5% (7.7% enoxaparin-assigned patients; 7.3% UFH-assigned patients; P = 0.4). In patients surviving 30 days after enrollment, independent predictors of 1-year mortality included factors known at baseline such as increased age, male sex, decreased weight, having ever smoked, decreased creatinine clearance, ST-segment depression, history of diabetes, history of angina, congestive heart failure, coronary artery bypass grafting, increased heart rate, rales, increased hematocrit, lowered hemoglobin, and higher platelet count. Factors predictive of mortality during the hospitalization and 30-day follow-up period were decreased weight at 30 days from baseline, atrial fibrillation, decreased nadir platelet, no use of beta-blockers and statins up to 30 days, and not receiving an intervention (c-index = 0.82).


CONCLUSIONS
Easily determined baseline clinical characteristics can be used to predict 1-year mortality with reasonable discriminative power. These models corroborate prior work in a contemporary aggressively managed population. A model to predict 1-year mortality in patients surviving at least 30 days may be quite helpful to healthcare providers in setting expectations and goals with patients after ACS.
Mahaffey
Kenneth W
KW
Duke Clinical Research Institute, Durham, NC 27715, USA. mahaf002@mc.duke.edu
Yang
Qinghong
Q
Pieper
Karen S
KS
Antman
Elliott M
EM
White
Harvey D
HD
Goodman
Shaun G
SG
Cohen
Marc
M
Kleiman
Neal S
NS
Langer
Anatoly
A
Aylward
Philip E
PE
Col
Jacques J
JJ
Reist
Craig
C
Ferguson
James J
JJ
Califf
Robert M
RM
D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D017023:Coronary Angiography / Q000379:methods; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004562:Electrocardiography; D017984:Enoxaparin / Q000008:administration & dosage*; D005260:Female; D005500:Follow-Up Studies; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016037:Single-Blind Method; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
D017984:Enoxaparin; D006495:Heparin, Low-Molecular-Weight