Coronary artery disease
Impact of Anemia on Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction in Relation to Gender and Adjunctive Antithrombotic Therapy (from the HORIZONS-AMI Trial)

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The aim of this study was to assess the impact of baseline anemia on the outcomes of patients with ST elevation myocardial infarctions who underwent primary percutaneous coronary intervention in relation to contemporary adjunctive antithrombotic therapy and gender. In the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, patients were randomized to bivalirudin alone or to unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor before primary percutaneous coronary intervention. Outcomes were assessed at 30 days and 1 year according to anemia and gender. Baseline anemia was present in 331 of 3,153 patients (10.5%). Patients with versus without baseline anemia had a more than twofold increase in major bleeding at 30 days (13.5% vs 6.7%, p <0.0001) and at 1 year (14.8% vs 7.2%, p <0.0001), an association that on multivariate analysis was independent of gender. Mortality was significantly higher in men with versus without baseline anemia (4.6% vs 1.8% at 30 days, p = 0.003; 8.9% vs 3.0% at 1 year, p <0.0001) but not in women (5.3% vs 3.6% at 30 days, p = 0.42; 7.5% vs 5.9% at 1 year, p = 0.54). On multivariate analysis, anemia independently predicted 1-year all-cause mortality in men but not in women. Bivalirudin compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor resulted in twofold lower rates of all-cause and cardiac mortality and major bleeding in patients without but not in those with baseline anemia. In conclusion, baseline anemia was associated with increased major bleeding and death in patients with ST elevation myocardial infarctions who underwent primary PCI but was a stronger predictor of early and late mortality in men than in women. Paradoxically, in this post hoc analysis, the reductions in major bleeding and mortality in ST elevation myocardial infarction afforded by bivalirudin occurred primarily in patients without baseline anemia.

Section snippets

Methods

The HORIZONS-AMI protocol, inclusion and exclusion criteria, and principal results have been reported in detail elsewhere.5 Briefly, 3,602 patients aged ≥18 years who had persistent ST-segment elevation ≥1 mm in ≥2 contiguous leads, new left bundle branch block, or true posterior infarctions and symptoms consistent with acute myocardial infarctions lasting >20 minutes but <12 hours who underwent primary PCI were randomized 1:1 to treatment with bivalirudin alone (Angiomax; The Medicines

Results

Patient flow and follow-up appear in Figure 1. Among a total of 3,602 patients in the HORIZONS-AMI trial, baseline hematocrit before angiography was available in 3,389 patients (94.1%), including 2,603 men (76.8%) and 786 women (23.2%). Primary PCI was attempted in a total of 3,153 of these patients (93.0%), including 2,441 of the men (77.4%) and 712 of the women (22.6%), who thus constituted the study population. From this group, anemia at baseline was present in 331 patients (10.5%),

Discussion

The main findings of the present analysis are that (1) the presence of baseline anemia was strongly associated with increased 30-day and 1-year mortality, but this relation was gender specific, with mortality independently related to anemia in men but not in women; (2) baseline anemia was a strong independent predictor of major bleeding regardless of gender; and (3) treatment with bivalirudin significantly reduced rates of all-cause and cardiac mortality, major bleeding, and combined adverse

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