The major element of 1-year prognosis in acute coronary syndromes is severity of initial clinical presentation: Results from the French MONICA registries.
BACKGROUND
While the death rate from acute coronary syndromes (ACS) has been in decline for more than 50 years, out-of-hospital mortality remains high despite improvements in care.


OBJECTIVE
To evaluate the importance of out-of-hospital mortality and identify the main predictors of in-hospital and 1-year mortality in France.


METHODS
Analyses were based on data from the French MONICA population-based registry, which included all cases of ACS occurring in people aged 35-74 years during 2006 in three geographic areas in France. We first evaluated out-of-hospital mortality; then, using data from patients with incident ACS who reached hospital alive, Cox models were performed to determine the main predictors of 1-year mortality. The number of attributable deaths was assessed for variables of interest.


RESULTS
After 1-year follow-up, case-fatality was 29.3% for incident events (n=2547); the proportion of out-of-hospital deaths was 70.3%, and 91.5% of deaths occurred in the 28 days following the ACS. On multivariable analysis, the number of attributable deaths associated with three scenarios (out-of-hospital life-and-death emergency, hospitalization before ACS occurrence, and lack of coronary angiography) was 130 (accounting for 59% of deaths occurring after reaching the hospital) during 1-year follow-up. These scenarios corresponded to patients with an initial severe clinical presentation in whom rates of use of specific treatments and invasive procedures were very low.


CONCLUSIONS
A large proportion of fatalities after an ACS occurs in the out-of-hospital phase. Moreover, the major component of 1-year mortality is associated with a poor prognosis at initial presentation. This finding highlights the importance of cardiovascular prevention, population education and better out-of-hospital emergency management in improving prognosis after an ACS.
Department of Cardiology A, Toulouse University Hospital, Rangueil Hospital, Toulouse, France.
Paul-Louis
PL
Vervueren
Meyer
M
Elbaz
Aline
A
Wagner
Jean
J
Dallongeville
Jean-Bernard
JB
Ruidavets
Bernadette
B
Haas
Michèle
M
Montaye
Vanina
V
Bongard
Dominique
D
Arveiler
Philippe
P
Amouyel
Jean
J
Ferrières
D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy; D000328:Adult; D000368:Aged; D002423:Cause of Death; D017023:Coronary Angiography; D005260:Female; D005602:France / Q000453:epidemiology; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors