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Accepted Manuscript
Contemporary management of patients referring to cardiologists
one to three years from a myocardial infarction: The EYESHOT
Post-MI study
Leonardo De Luca, Federico Piscione, Furio Colivicchi, Donata
Lucci, Franco Mascia, Barbara Marinoni, Plinio Cirillo, Daniele
Grosseto, Ciro Mauro, Paolo Calabrò, Federico Nardi, Roberta
Rossini, Giovanna Geraci, Domenico Gabrielli, Andrea Di
Lenarda, Michele Massimo Gulizia, EYESHOT Post-MI
Investigators
PII:
DOI:
Reference:
S0167-5273(18)33347-3
doi:10.1016/j.ijcard.2018.08.055
IJCA 26871
To appear in:
International Journal of Cardiology
Received date:
Revised date:
Accepted date:
21 May 2018
27 July 2018
17 August 2018
Please cite this article as: Leonardo De Luca, Federico Piscione, Furio Colivicchi, Donata
Lucci, Franco Mascia, Barbara Marinoni, Plinio Cirillo, Daniele Grosseto, Ciro Mauro,
Paolo Calabrò, Federico Nardi, Roberta Rossini, Giovanna Geraci, Domenico Gabrielli,
Andrea Di Lenarda, Michele Massimo Gulizia, EYESHOT Post-MI Investigators ,
Contemporary management of patients referring to cardiologists one to three years from
a myocardial infarction: The EYESHOT Post-MI study. Ijca (2018), doi:10.1016/
j.ijcard.2018.08.055
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ACCEPTED MANUSCRIPT
Contemporary Management of Patients Referring to Cardiologists One to Three Years
from a Myocardial Infarction: The EYESHOT Post-MI Study
Leonardo De Luca, MD, PhD, FACC, FESC1; Federico Piscione, MD, FESC2; Furio
Colivicchi, MD, FESC3; Donata Lucci, BSc4; Franco Mascia, MD5; Barbara Marinoni, MD6;
Plinio Cirillo, MD, PhD7; Daniele Grosseto, MD8; Ciro Mauro, MD9; Paolo Calabrò, MD,
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PhD, FESC10; Federico Nardi, MD, FACC, FESC11; Roberta Rossini, MD12; Giovanna
Geraci, MD13; Domenico Gabrielli, MD14; Andrea Di Lenarda, MD, FESC15; Michele
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Massimo Gulizia, MD, FACC, FESC16; on behalf of the EYESHOT Post-MI Investigators*
1
Division of Cardiology, S. Giovanni Evangelista Hospital, Tivoli (Roma); 2Division of Preventive
Cardiology, SS Giovanni di Dio e Ruggi d'Aragona Hospital, University of Salerno; 3Division of
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Cardiology, S. Filippo Neri Hospital, Roma; 4ANMCO Research Center, Firenze; 5Division of
Cardiology,. S. Anna and Sebastiano Hospital, Caserta; 6Fondazione IRCCS Pol. S. Matteo, Pavia;
Cardiology Unit, Federico II University of Naples; 8Department of Cardiovascular Diseases, AUSL
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Rimini; 9Division of Cardiology, AORN Cardarelli, Napoli; 10 Division of Cardiology; AORN Ospedale
dei Colli- Monaldi, Napoli; 11Division of Cardiology, Santo Spirito Hospital, Casale Monferrato (AL);
Division of Cardiology, S. Croce e Carle Hospital, Cuneo; 13Division of Cardiology, Azienda Ospedali
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Riuniti Villa Sofia-Cervello, Palermo;14Division of Cardiology, Augusto Murri Hospital, Fermo;
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Division of Cardiology, Azienda Sanitaria Universitaria Integrata di Trieste; 16Division of Cardiology,
Garibaldi-Nesima Hospital, Catania, Italy.
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*See Appendix for a complete list of centres and Investigators
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Running title: EYESHOT Post-MI
Word count: 4178; 20 references, 1 Table, 3 Figures
Corresponding author:
Leonardo De Luca, MD, PhD, FACC, FESC
Division of Cardiology, Interventional Cardiology Unit
Ospedale San Giovanni Evangelista, Via Parrozzani, 3 - 00019 Tivoli-Roma, Italy
Email: leo.deluca@libero.it; Phone: +39-0774-3164806; Fax: 39-0774-3164808
EYESHOT Post-MI Coordinating Center, Centro Studi ANMCO
Via Alfonso La Marmora, 34 - 50121 Firenze (Italia) Tel +39 055/5101361, fax +39 055/5101310
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ABSTRACT
Aims. To describe the contemporary management by cardiologists of patients after an
episode of myocardial infarction (MI).
Methods. The EYESHOT Post-MI was a prospective, observational, nationwide study
aimed to evaluate the management of patients referring to cardiologists 1 to 3 years from the
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last MI event.
Results. Over a 3-month period, 1633 consecutive patients [median 22 (IQR 15-28) months
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from MI] were enrolled: 1028 (63.0%) at the second and 605 (37.0%) at the third year from
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MI. During the 12 months prior to enrolment, the majority of patients received a
transthoracic echocardiogram (60% and 54%), followed by coronary angiography (24% and
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16%, in the second and third year from MI groups, respectively). At the time of enrolment,
the majority of patients were prescribed on statins (93%) and beta-blockers (82%), without
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significant differences between the 2 groups. A dual antiplatelet therapy (DAPT) was used
more frequently among patients presenting during the second compared to the third year
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from MI (40% vs 24%; p<0.0001). At multivariable analysis, the time interval from last MI
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(2 vs 3 years: OR 2.27; 95% CI 1.79-2.88; p<0.0001) and a previous percutaneous coronary
intervention with multiple stents (OR 3.46; 95% CI 2.19-5.47; p<0.0001) resulted as the
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major independent predictors of DAPT persistence at the time of enrolment.
Conclusions. This contemporary registry provides unique insights into the current
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management of post-MI patients and represents an opportunity to further improve the longterm treatment of this high-risk population.
Abstract word count: 238
Key words: post-MI; secondary prevention; percutaneous coronary intervention; dual antiplatelet therapy;
ticagrelor; clopidogrel.
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1.0 INTRODUCTION
In the last decades, remarkable improvements have been made in the care of myocardial
infarction (MI). Nevertheless, MI survivors remain at high risk for recurrent cardiovascular
events at long-term follow-up (1,2). Current international guidelines recommend the use of
several pharmacological therapies, in addition to lifestyle interventions and risk factor
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control, in order to improve the outcome of this high-risk patient population (3,4). However,
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secondary prevention strategies in a real-world setting seem not completely adherent to
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guidelines recommendations (5,6). One of the reason of this suboptimal care might be
related to the fact that management protocols for MI follow-up are not clearly defined and
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long-term specialist care is not commonly provided.
The aim of the EYESHOT (EmploYEd antithrombotic therapies in patients with acute
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coronary Syndromes HOspitalized in iTaly) Post-MI study was to assess the current
management by cardiologists of patients referring to cardiologists one to three years from a
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MI.
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2.0 METHODS
The EYESHOT Post-MI was a prospective, observational, nationwide study of consecutive
patients with a prior MI managed by cardiologists. All patients admitted in cardiology units
and/or ambulatory clinics during a period of 3 months with a documented history of
presumed spontaneous MI event (non-ST elevation, NSTEMI or ST-elevation-MI, STEMI)
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occurred between 1 and 3 years before enrolment have been included. We excluded patients
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with a diagnosis of MI in the year before the enrolment, those with known pregnancy,
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breast-feeding, or intend to become pregnant during the study period (or other conditions
that would contraindicate the use of some drugs), those already included in studies requiring
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interventions and those not giving informed consent. Enrolment was made at the beginning
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of outpatient or day-hospital visit or at hospital admission.
Data were analysed for two pre-specified groups of patients: (1) those referred to
cardiologists from 12 to 24 months (second year) and (2) from 25 to 36 months (third year)
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after the last MI event.
The Italian Association of Hospital Cardiologists (ANMCO) designed and endorsed the
study. ANMCO invited to participate all Italian cardiology wards, including university
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teaching hospitals, general and regional hospitals, and private clinics receiving post-MI
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patients. No specific protocols for evaluation, management, and/or treatment have been put
forth during this observational study. However, current guidelines for the management of
STEMI and NSTE-ACS (4,5) have been discussed during the investigator meetings.
All patients were informed of the nature and aims of the study and asked to sign an informed
consent for the anonymous management of their individual data. Local Institutional Review
Boards (IRB) approved the study protocol according to the current Italian rules.
2.1 Data collection and definitions
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Data on baseline characteristics, including demographics, risk factors and medical history, were
collected. Information on the use of diagnostic cardiac procedures, type and timing of
revascularization therapy (if performed) and use of pharmacological or non-pharmacological
therapies were recorded on an electronic case report form (CRF; available at
www.anmco.it/eyeshotpostmi).
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At each site, the principal investigator was responsible for screening consecutive eligible patients.
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Data were collected using a web-based, electronic CRF with the central database located at the
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ANMCO Research Center. By using a validation plan, integrated in the data entry software, data
were checked for missing or contradictory entries and values out of the normal range.
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Hypertension was defined as a systolic blood pressure >140 mmHg or diastolic blood pressure
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>90 mmHg or use of blood pressure lowering drugs. A diagnosis of chronic renal dysfunction was
made in case of dialysis, history of renal transplant or creatinine levels >1.5 mg/dL. Peripheral
artery disease was diagnosed in case of history of claudication; amputation for arterial
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insufficiency; aorta-iliac occlusive disease reconstruction surgery; peripheral vascular bypass
surgery, angioplasty, or stent; documented abdominal aortic aneurysm, aneurysm repair or stent;
and documented positive non-invasive testing such as abnormal ankle-brachial index or pulse
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volume recording. History of major bleeding events was defined as fatal bleeding, or clinically
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evident bleeding with haemoglobin reduction ≥ 2g/dL or requiring transfusion or hospitalization
2.2 Statistical analysis
Categorical variables are presented as number and percentages and compared by the chisquared test. Continuous variables are presented as mean and standard deviation (SD),
except for body mass index (BMI), triglycerides and timing from last MI, which are reported
as median and interquartile range (IQR). The study cohort was stratified according to the
timing from the last MI (i.e. from 12 to 24 months and from 24 to 36 months). Continuous
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variables were compared by the t test, if normally distributed, or by the Mann-Whitney U
test, if not.
Clinically relevant variables were included in a multivariable model (logistic regression), to
identify the independent predictors of dual antiplatelet therapy (DAPT) assumption at the
time of enrolment. The variables included in the model were: age (as continuous variable),
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gender, diabetes mellitus, renal insufficiency, history of peripheral artery disease, history of
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major bleeding events, prior percutaneous coronary intervention (PCI) and number of stent
implanted (No PCI-reference group; PCI and≤2 stents; PCI and >2 stents), type of last
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myocardial infarction (STEMI vs NSTEMI), type of enrolment (hospital admission vs
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outpatient visit), time from last MI (12-24 vs 25-36 months), use of oral anticoagulant at
time of enrolment, and multiple MIs. When more than two categories were present, dummy
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variables were introduced to define a reference group. A p value < 0.05 was considered
statistically significant. All tests were 2-sided. Analyses were performed with SAS system
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software, version 9.4.
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3.0 RESULTS
Each site started patient enrollment after local IRB approval. Therefore, data were collected
in different periods of consecutive 3 months in each site between March 6th, 2017 and
December 16th, 2017. Over these periods, 1633 consecutive patients [median 22 (IQR 15-28)
months from MI] were enrolled: 1028 (63.0%) presenting to a cardiologist during the second
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[median 17 (IQR 14-21) months] and 605 (37.0%) during the third year from MI [median 30
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(IQR 27-33) months].
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The study has been carried out in 165 cardiology centers: a mix of hospitals with noninvasive diagnostic facilities only (41%) and hospitals with catheterization laboratory and/or
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cardiac surgery onsite (59%), well representing the Italian cardiology reality in terms of
geographical distribution and level of hospital technology. The vast majority of patients
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were enrolled during outpatient or day hospital visits (84%) and the remaining during
hospital admissions (16%).
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Baseline characteristics of the study population are shown in Table 1. The mean age of
enrolled patients was 66±12 years, 80% were male, 28% diabetics, 74% had
hypercholesterolemia and 18% prior multiple MIs (Table 1). Among patients with data
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available, the mean ejection fraction was 52%, a systolic blood pressure ≤140 mmHg was
present in 82%, a heart rate ≤70 bpm in 71% and LDL cholesterol levels ≤70 mg/dl in 49%
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of cases, without significant differences between the two groups.
3.1 Diagnostic procedures and treatments
Diagnostic cardiac procedures performed in the 2 groups within the previous 6 and 12
months from enrolment are shown in Figure 1. During the 12 months prior to enrolment the
majority of patients received a transthoracic echocardiogram (54% and 60%), followed by
coronary angiography (24% and 16%) and stress test (22% and 18%) in the second and third
year from MI groups, respectively.
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Among patients enrolled, 15% were on diet, a regular physical activity was performed by
28% and 61% of smokers at the time of last MI declared to have stopped smoking, without
significant differences between the two groups.
At the time of enrolment, the majority of patients were prescribed on statins (93%), followed
by beta-blockers (82%), angiotensin converting enzyme inhibitors/angiotensin receptor
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blockers (75%) and diuretics (28%), while drugs for angina relief were used in a minority of
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cases, without significant differences between the 2 groups of patients (Figure 1Suppl).
Regarding antiplatelet drugs, aspirin was used in 90%, a thienopyridine in 40% and DAPT
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in 34% of patients. The latter was used more frequently among patients presenting in the
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second year compared to those referring in the third year from MI (40% vs 24%; p<0.0001)
(Figure 3). Among patients receiving DAPT, the most frequently used association was
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aspirin and clopidogrel (45% and 79%, for those managed in the second and third year from
MI, respectively) (Figure 2A).
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At multivariable analysis, several variables resulted as independent predictors of DAPT
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persistence at the time of enrolment (Figure 3), mainly the time interval from MI (2 vs 3
years: OR 2.27; 95% CI 1.79-2.88; p<0.0001) , a previous PCI with multiple stents (OR
3.46; 95% CI 2.19-5.47; p<0.0001), with a lower prescription of DAPT in patients treated
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with anticoagulants (OR 0.12; 95% CI 0.07-0.23; p<0.0001).
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At discharge/end of the visit, among the 1632 outpatients/patients discharged alive, the
pharmacological therapy was modified in 406 (39.5%) and 181 (29.9%) patients at the
second and the third year from MI, respectively (p<0.0001). Above all variations were
attributable to DAPT (9% and 2% absolute reduction for patients at the second and third
year from MI, respectively) (Figure 2A and B), while for all other cardiovascular therapies
less than 1% absolute reduction changes were reported.
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4.0 DISCUSSION
The present study provides unique contemporary nationwide data on clinical characteristics,
healthcare resource utilization and treatment patterns of patients managed by cardiologists in
routine clinical practice 1 to 3 years after a MI.
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Patients who have survived acute MI have an increased risk of subsequent cardiovascular events,
including recurrent MI, stroke, and death from cardiovascular disease compared with CAD-free
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subjects of similar age and sex (1-9). Data from the REACH registry showed an incidence of a
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new cardiovascular event of 18% at 4 years in patients with history of MI or stroke (1). Recently,
the APOLLO dataset, that linked registries and administrative data, showed that the risk of
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cardiovascular events in MI survivors is approximately 20% across the first three years from MI
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(7). Accordingly, in a large nationwide Swedish registry that is part of the APOLLO project, the
cumulative probability of a subsequent event in the stable post-MI population was 9% after 12
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months and 20% after 36 months (2).
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In order to improve the prognosis of these patients, recent guidelines recommend a multifaceted
approach including lifestyle modification, risk factors control and evidence-based
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pharmacological therapies, generally discouraging the use of non-invasive testing on a regular
basis (3,4). Our data show that the use of non-pharmacological secondary prevention strategies is
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still suboptimal and need specific implementation campaigns in our country. On the other hand,
diagnostic cardiac procedures, especially transthoracic echocardiogram and coronary angiography,
are largely employed during follow-up, as also reported in other european and north-american
studies (10-13).
In many countries, the real-world management of patients after a MI may differ based on the
available infrastructure, guideline adherence, health economy, cultural barriers and local treatment
patterns. In Italy, acute MI is usually managed in cardiology units with low rates of in-hospital
cardiovascular events (14,15), while long-term follow-up is generally left to primary care
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physicians with scarce data on patients’ persistence to drugs prescribed at the time of hospital
discharge. Our registry shows that post-MI patient receive an acceptable rate of pharmacological
therapies recommended for secondary prevention. Other drugs, such as diuretics, have been
prescribed in a high number of cases, especially when the number of enrolled patients with a
history of heart failure is considered, since also thiazide compounds used as anti-hypertensive
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medication were included in this class of agents. Notably, the only major changes in therapy made
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by cardiologists during the visits or hospitalization were focused on DAPT that was considerably
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reduced, especially among patients presenting at the second year from MI.
In patients with a prior MI, DAPT is strongly recommended for up to 12 months in order to reduce
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recurrent cardiovascular events (2,3). The EPICOR study (Long-Term Follow-Up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients), conducted in 2010-2011
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in 20 countries, showed that more than half of patients with MI remained on DAPT beyond 12
months in Europe and Latin America (8). Subsequently, the TIGRIS registry, conducted in 2013-
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2014 in 25 countries, documented a DAPT continuation beyond 1 year in 12% of post-MI patients
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with high-risk features enrolled in Europe, 25% in North America and 40% in Asia-Pacific
countries (9). This reduction in the frequency of DAPT duration observed over few years could be
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ascribed to a growing awareness of bleeding events associated with DAPT prolongation or fewer
concerns related to late stent thrombosis with the advent of last generation drug-eluting stents.
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However, in both international registries (8,9), the country and the presence of frequent PCI with
multiple stenting represented the most important determinants of the proportion of patients
remaining on DAPT 1 year after the index MI. Even in our cohort, the presence of multiple stents,
together with the time interval from MI, were the major predictors of DAPT prolongation,
confirming that the duration of DAPT may be mostly conditioned by the complexity of PCI,
together with cultural, economic and organisational factors, rather than individual patient’s risk.
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In our contemporary series, DAPT, mainly based on aspirin and clopidogrel, was prolonged
beyond the first year in 34% of cases. This high rate could be justified by evidences recently
derived from two randomized clinical trials. Indeed, the DAPT (Dual Antiplatelet Therapy Study)
and PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients with Prior Heart Attack
Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial
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Infarction 54) trials (16,17) showed a reduction in ischaemic events with a significant increase in
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major bleeding, but excluding intracranial haemorrhage and fatal bleeding events. Given these
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reasons international guidelines suggest considering DAPT prolongation beyond the first year
from MI in patients at high risk for recurrent ischemic events after careful assessment of bleeding
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risk (3,4,18). In our study, ticagrelor 60 mg BID, largely tested in the PEGASUS-TIMI 54 trial
(17), was prescribed in < 5% of DAPT-treated patients. This figure underlines the need for
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educational programmes on the correct identification of patients who could benefit most from
DAPT prolongation and the consequent proper treatment.
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On the other hand, approximately 6% of our population was chronically managed with a
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P2Y12 inhibitor but without concomitant aspirin. This finding could be partially ascribed to
aspirin intolerance or hypersensitivity that is not uncommon in routine clinical practice and
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need specific treatment protocols (19,20).
4.1 Study Limitations
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Our study must be evaluated in the light of the known limitations of observational, crosssectional studies. In addition, even if the participating centers were asked to include in the
registry all consecutive post-MI patients, we were not able to verify the enrolment process,
due to the absence of administrative auditing. We believe that it is unlikely however that
selective enrolment in few sites may have substantially changed the study results.
Nevertheless, it should be noticed that about 3 patients per month by each center were
enrolled during the study period. This number seems reasonable if all inclusion/exclusion
criteria are considered, especially the specific time range (2-3 years) from MI that was
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required for enrolment. In addition, the 3-month recruitment period was not homogeneous and
depended on the time of IRB approval of each center, but this issue should not have
influenced the modalities of pharmacological and non-pharmacological treatment of patients
enrolled. Finally, we specifically enrolled post-MI patients referring to cardiologists.
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Therefore, our data are not likely representative of routine non-specialist clinical practice.
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5.0 CONCLUSIONS
This study provides unique insights into the current management and treatment of patients
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with prior MI 1-3 years ago referring to a cardiologist. The majority of patients were
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receiving evidence-based secondary prevention medical therapies. Approximately 1 out of 3
patients received DAPT beyond the first year from MI. The interval from the MI event and
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PCI with multiple stenting resulted as the major predictors of DAPT prolongation.
These findings represent an opportunity to further improve the long-term management of
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post-MI patients in the light of recent evidence in this field.
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Acknowledgements
The authors would like to thank Barbara Bartolomei Mecatti for editorial assistance.
Funding
The sponsor of the study was the Heart Care Foundation, a non-profit independent
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organization, which also owns the database. Database management, quality control of the
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data and data analyses were under the responsibility of the ANMCO Research Centre Heart
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Care Foundation. The study was partially supported by an unrestricted grant by Astra
Zeneca, Italy. No compensation was provided to participating sites, investigators, nor
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members of the Steering Committee. The Steering Committee of the study had full access to
all of the data in this study and takes complete responsibility for the integrity of the data and
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Conflicts of interest
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the accuracy of the data analysis.
Dr. De Luca reports personal fees from Amgen, Aspen, Astra Zeneca, Bayer, Boeringer
Ingelhaim, Daiichi Sankyo, Menarini, Pfizer, outside the submitted work; Dr. Rossini
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Pfizer.
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reports personal fees from Astra Zeneca, Bayer, Boehringer, Daiichi Sankyo, Novartis,
Lucci is an employee of Heart Care Foundation, which conducted the study with an
unresctricted grant of research from Astra Zeneca, Italy.
All other authors have reported that no potential conflicts of interest exist with any
companies/organizations whose products or services may be discussed in this article.
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survey and systematic review. Circ Cardiovasc Interv 2016;9(1):e002896.
20. Rossini R, Iorio A, Pozzi R, et al. Aspirin desensitization in patients with coronary artery
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disease: results of the multicenter ADAPTED Registry (Aspirin Desensitization in Patients
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With Coronary Artery Disease). Circ Cardiovasc Interv 2017;10(2):e004368.
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FIGURE LEGENDS
Figure 1. Diagnostic procedures performed 6 and 12 months before enrolment in the 2 groups
(12-24 months and 25-36 months from last MI).
CCTA: Coronary computed tomography angiography; MRI: Magnetic Resonance
Imaging.
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Figure 2. Antiplatelet strategies at enrolment (panel A) and at the end of the visit or hospital
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discharge (panel B)
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Figure 3. Multivariable logistic regression analysis on DAPT at the time of enrolment.
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PAD: peripheral artery disease.
Figure 1 Suppl. Cardiovascular therapies (excluding antiplatelet agents) at enrolment in the 2
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groups (12-24 months and 25-36 months from last MI) *.
*Drugs not reported have been used in less than 5% of the cases
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ACE: angiotensin-converting-enzyme inhibitors; ARB: angiotensin receptor blockers;
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CCB: calcium channel blockers; MRA: mineralocorticoid receptor antagonists; OAC:
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oral anticoagulants
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APPENDIX
Steering Committee
L De Luca (Chairman), MM Gulizia (Co-Chairman), F Colivicchi, A Di Lenarda, D Gabrielli, G Geraci,
F Nardi, R Rossini
Coordinating Center
ANMCO Research Center (AP Maggioni, D Lucci, A Lorimer, G Orsini, L Gonzini, P Priami)
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Participating Centers and Investigators
Salerno (F Piscione, A Silverio, RM Benvenga); Caserta, A.O. S. Anna e S. Sebastiano (F Mascia, A Fusco,
S Cicala); Pavia, Fondazione IRCCS Pol. S. Matteo, (L Oltrona Visconti, B Marinoni, U Canosi); Napoli,
AOU Federico II (P Cirillo, B Trimarco, F Ziviello); Rimini (D Grosseto, M Menozzi, D Mezzena); Napoli,
AORN Cardarelli, Cardiologia c/UTIC (C Mauro, A Sasso, A Bellis); Napoli, AORN Osp. dei Colli-PO V.
Monaldi (P Calabrò, F Gragnano, A Cesaro); Roma, S. Pertini (V Venturelli, V Porretta, N Borrelli);
Catanzaro, Materdomini (C Indolfi, S De Rosa, D Torella); Milano, Niguarda, Cardiologia 1 (N Morici);
Genova, Galliera (P Bernabò, M Molfese, F Della Rovere); Monfalcone (G Lardieri, T Caiffa, G Moretto);
Prato (G Grippo, E Di Vincenzo); Tivoli (A Granatelli, L Lucisano, M Pennacchi); Gorizia (G Lardieri, T
Caiffa); Palermo, Villa Sofia-Cervello (G Geraci, N Sanfilippo, A Ledda); Trieste (A Di Lenarda, A
Cherubini, G Russo); Frattamaggiore (F Piemonte, A Di Donato, A Carraturo); Benevento, Sacro Cuore di
Gesù FBF (B Villari, Q Ciampi, C Contaldi); Rozzano (V Pacher, E Corrada, D Cattani); Saronno (D
Nassiacos, S Meloni, B Barco); Trento (R Bonmassari, A Bertoldi, F Tedoldi); Andria (M Cannone, G
Valenti, RL Musci); Bari, San Paolo (P Caldarola, N Locuratolo, L Sublimi Saponetti); Brescia (L Gentili, C
Maiandi); Chieti (M Caputo, CA Capparuccia); Milano, Maggiore Policlinico (T Tonella, FM Massari);
Verbania (A Lupi, M Tessitori, M Montano); Milano, S.M. Nascente (A Scaglione, A Torri); Reggio Emilia
(G Tortorella, A Navazio); Bolzano (R Cemin, L Latina); Castellanza (D Briguglia, R Marino); Lumezzane
(S Scalvini, E Zanelli); Montescano (V Paganini, G Riboni); Pordenone (E Leiballi, A Della Mattia);
Rovereto (F Imperadore); Seriate (M Tespili, G Santangelo); Borgomanero (U Parravicini, P Dellavesa);
Cecina (R Testa, E Venturini); Fossano (M Feola, M Testa); Lentini (V Crisci, M Tramontana); Lido di
Camaiore (L Robiglio); Rivoli (F Varbella, I Meynet); Roma, Villa Betania (A Galati, A Maddaluna);
Arzignano (C Bilato, I Loddo); Augusta (G Licciardello, L Cassaniti); Benevento, G. Rummo (M Scherillo,
D Formigli); Castel Volturno (L Marullo, L Chianese); Corato (C Paolillo, APA De Santis); Foggia (ND
Brunetti, D Bottigliero); Roma, Casilino (R Della Bona, MB Giannico); San Donato Milanese, IRCCS,
Cardiologia Riabilitativa (R Tramarin, S Lucibello); Ancona, Riuniti (GP Perna, M Marini); Campobasso
(AR Colavita); Catania, Garibaldi-Nesima (MM Gulizia, GM Francese); Cuggiono (M Mariani, F Collauto);
Magenta (M D'Urbano, R Naio); Messina (G Andò, F Saporito); Milano, Monzino (EM Assanelli, A
Cabiati); Paola (A Crivaro, S Alberti); Rieti (I Marchese); Roma, Clinica Città di Roma (T Nejat, S Refice);
Roma, PO S. Filippo Neri, Cardiologia e UTIC (F Colivicchi, A Aiello); Roma, PO S. Filippo Neri, Card.
Riab.-PO Salus (A Galati, GR Cristinziani); Roma, Umberto Primo (F Barillà, R Iorio); Sanremo (G
Mascelli, SN Tartaglione); Santa Maria Capua Vetere (G Di Chiara, D D'Andrea); Ancona, INRCA (R
Antonicelli, G Malatesta); Firenze (C Di Mario, A Mattesini); Spoleto (L Tramontana, S Conti); Viterbo (L
Sommariva, A Celestini); Catania, Cannizzaro (F Amico, S Giubilato); Galatina (AF Amico, M De Filippis);
Gavardo (GF Pasini, M Triggiani); Manfredonia (V Ferrara, S Cappetti); Milano, San Paolo (S Carugo, S
Lucreziotti); San Benedetto Del Tronto (M Persico, G Gizzi); Cefalù (T Cipolla, A Caronia); Fidenza (E
Buia, P Pastori); Foligno (M Scarpignato, E Biscottini); Legnano (F Poletti, C Vimercati); Milano, Niguarda,
Cardiologia 4 (R Pirola); Negrar (E Barbieri, C Dugo); Osio Sotto (N De Cesare, ML De Benedictis); Reggio
Calabria, Madonna della Consolazione (A Ruggeri); San Fermo della Battaglia (C Campana, S Bonura); San
Giovanni Rotondo (C Vigna, N Marchese); Sondalo (NG Partesana, P Bandini); Cassano delle Murge (G
Farinola, D Santoro); Catanzaro, Pugliese (F Cassadonte); Empoli (F Calabrò, M Sansoni); Erice (MG
Abrignani, F Bonura); Fermo (D Gabrielli, M Benvenuto); Lecce (A Liso, T Passero); Milano, CTO (I Mori,
B Pozzoni); Roma, S.G. Addolorata (F Prati, ML Finocchiaro); Sorrento (N Tufano); Melito di Porto Salvo
(B Miserrafiti, V Lacquaniti); Mestre, San Marco (F Del Piccolo, B Mohamad); Moncalieri (MT Spinnler, V
Bovolo); Palermo, Casa di Cura Candela (E Rebulla, M Pieri); Pescara (L Paloscia, D Di Clemente);
Piossasco (G Mazzucco, A Micanti); Ponte San Pietro (P Peci, O Ornago); Roma, Aurelia Hospital (F
Proietti, M Michisanti); Scandiano (A Reverzani, A Donatini); Avola (P Costa, S Russo); Belluno (E
Franceschini Grisolia, L Mario); Boscotrecase (F Di Palma, F Dell'Aquila); Busto Arsizio (A Maestroni, SI
Caico); Castellammare di Stabia (G De Caro, L Attianese); Esine (S Perotti, V Cotti Cometti); Genova,
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Padre Antero Micone (D Astengo); Guastalla (A Navazio, E Guerri); Milano, S. Raffaele (D Cianflone, F
Maranta); Napoli, Fond. Evangelica Betania (N Esposito, M Malvezzi Caracciolo D'Aquino); Nola (L
Caliendo, C Ricci); Reggio Calabria, Bianchi Melacrino Morelli (CP Ceruso, S Lanteri); Roma, S. Pietro
FBF (R Serdoz, E Bruno); San Felice a Cancello (C De Matteis, C Campagnuolo); San Giuseppe Vesuviano
(MA Ammirati, VM Corrado); Arco (MA Amado Eleas); Aversa (L Fattore); Avezzano (C Ippoliti);
Conegliano (G Turiano); Feltre (C Piergentili); Gallarate (SI Caico); Genova, S. Martino (F Chiarella);
Napoli, S.G. Bosco (P Capogrosso); Pavia, ICS Maugeri SPA Società Benefit (M Perotti); Pescia (S Di
Marco); Pozzuoli (G Sibilio); Sessa Aurunca (L Di Lorenzo); Taranto (A Aurelio); Vicenza (AB Ramondo);
Bari, Policlinico (D Zanna); Castelfranco Veneto (C Cernetti); Giugliano in Campania (G Napolitano); Imola
(S Negroni); Latina (N Alessandri); Mestre, Dell'Angelo (F Rigo); Molfetta (F Giusti); Nuoro (G Casu);
Peschiera Del Garda (A Vicentini); Policoro (G Calculli); Pomezia (MS Fera); Vittoria (GV Lettica);
Volterra (G Vagheggini); Bergamo (A Pitì); Caserta, Villa del Sole (A Porfidia); Ciriè (A Di Leo); Ivrea (A
Ravera); Licata (E Ciotta); Mirano (S Saccà); Napoli, AORN Cardarelli, Cardiologia Generale
c/Riabilitazione (O Silvestri); Piombino (S Isidori); S. Omero (P Natali); San Bonifacio (M Anselmi); San
Donato Milanese, IRCCS, Cardiologia c/UTIC (L Testa); Sesto San Giovanni (A Antonelli); Sondrio (E
Tavasci); Telese (G Furgi); Teramo (A Lavorgna); Treviso (N Gasparetto); Udine (T Bisceglia)
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Table 1. Baseline clinical characteristics, hemodynamic and laboratory variables of patients
presenting in the second and the third year from MI.
Months from last MI
Overall
>12-≤24
>24-≤36
N=1633
n=1028
n=605
Age (years), mean±SD
66±12
66±12
67±11
Age >75 years, n (%)
376 (23.0)
225 (21.9)
Females, n (%)
319 (19.5)
198 (19.3)
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825 (50.5)
P value
0.02
151 (25.0)
0.15
121 (20.0)
0.72
520 (50,6)
305 (50,4)
508 (49,4)
300 (49,6)
26.6
26.7
26.5
[24.7-29.3]
[24.7-29.4]
[24.7-29.1]
308 (18.9)
197 (19.2)
111 (18.4)
0.68
461 (28.2)
281 (27.3)
180 (29.8)
0.29
1283 (78.6)
807 (78.5)
476 (78.7)
0.93
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Type of last MI, n (%)
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population
Hypercholesterolemia, n (%)
1212 (74.2)
754 (73.4)
458 (75.7)
0.29
History of atrial fibrillation, n (%)
209 (12.8)
129 (12.6)
80 (13.2)
0.69
Chronic renal dysfunction, n (%)
203 (12.4)
129 (12.6)
74 (12.2)
0.85
Peripheral artery disease, n (%)
112 (6.9)
64 (6.2)
48 (7.9)
0.19
COPD¸ n (%)
187 (11.5)
125 (12.2)
62 (10.3)
0.24
68 (4.2)
38 (3.7)
30 (5.0)
0.22
50 (3.1)
31 (3.0)
19 (3.1)
0.89
STEMI
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808 (49.5)
BMI (kg/m2), median [IQR]
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Hypertension, n (%)
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Diabetes mellitus, n (%)
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Active smokers, n (%)
Previous stroke/TIA, n (%)
History of major bleeding events, n
(%)
0,95
0.97
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253 (15.5)
164 (16.0)
89 (14.7)
0.50
Multiple MIs, n (%)
293 (18.0)
181 (17.6)
112 (18.5)
0.65
Prior PCI, n (%)
1457 (89.2)
925 (90.0)
532 (87.9)
0.20
Prior CABG, n (%)
171 (10.5)
91 (8.9)
80 (13.2)
0.005
52±10
52±10
53±10
0.43
SBP (mmHg), mean±SD
130±17
130±17
130±17
0.69
HR (bpm), mean±SD
67±12
67±12
67±12
0.78
13.6±1.8
13.7±1.7
0.44
1.1±0.5
1.1±0.5
1.1±0.4
0.31
145±36
145±37
146±34
0.59
77±30
77±30
76±28
0.79
106
105
106
[80-145]
[80-151]
[80-140]
112±32
112±33
112±31
Ejection fraction (%), mean±SD
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History of heart failure, n (%)
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13.7±1.8
available for 1110 (68.0%) pts
Creatinine (mg/dl), mean±SD
available for 1119 (68.5%) pts
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Total cholesterol (mg/dl),
available for 1000 (61.2%) pts
LDL cholesterol, mean±SD
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available for 903 (55.3%) pts
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mean±SD
Triglycerides (mg/dl), median
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Hb (gr/dl), mean±SD
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available for 1474 pts
0.55
available for 979 (60.0%) pts
Glycemia (mg/dl), mean±SD
0.40
available for 993(60.8%) pts
BMI: body mass index; COPD: chronic obstructive pulmonary disease; Hb: hemoglobin; HR: heart
rate; IQR: inter-quartile range; LDL: low density lipoprotein; MI: myocardial infarction; NSTEMI:
non-ST elevation MI;SBP: systolic blood pressure; STEMI: ST-elevation MI TIA: transient
ischemic attack.
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Highlights
Contemporary Management of Patients Referring to Cardiologists One to Three Years
The EYESHOT Post-MI was a prospective, observational, nationwide study aimed to
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from a Myocardial Infarction: The EYESHOT Post-MI Study
evaluate the management of patients referring to cardiologists 1 to 3 years from the
Over a 3-month period, 1633 consecutive patients [median 22 (IQR 15-28) months
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last MI event.
from MI] were enrolled: 1028 (63.0%) at the second and 605 (37.0%) at the third
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year from MI.
During the 12 months prior to enrolment, the majority of patients received a
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transthoracic echocardiogram (60% and 54%), followed by coronary angiography
A dual antiplatelet therapy (DAPT) was used more frequently among patients
presenting during the second compared to the third year from MI (40% vs 24%;
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p<0.0001). At multivariable analysis, the time interval from last MI (2 vs 3 years:
OR 2.27; 95% CI 1.79-2.88; p<0.0001) and a previous percutaneous coronary
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(24% and 16%, in the second and third year from MI groups, respectively).
intervention with multiple stents (OR 3.46; 95% CI 2.19-5.47; p<0.0001) resulted as
the major independent predictors of DAPT persistence at the time of enrolment.
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Figure 1
Figure 2
Figure 3
Figure 4
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