Timing of mortality after severe bleeding and recurrent myocardial infarction in patients with ST-segment-elevation myocardial infarction

Background: The prognosis of initial survivors of ST-segment-elevation myocardial infarction (STEMI) is affected by both recurrent myocardial infarction (MI) and severe bleeding. The aim of the current study was to investigate how mortality is affected in time after bleeding and recurrent MI.

Methods and results: From January 1, 2003, to July 31, 2008, a total of 2002 patients were treated with primary percutaneous coronary intervention for ST-segment-elevation MI and followed up for the occurrence of recurrent MI and Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO) severe bleeding. Primary outcome was all-cause mortality within 4 years of follow-up. In a time-dependent, covariate-adjusted Cox regression model, both bleeding and recurrent MI were associated with an increase in mortality shortly after the adverse event: hazard ratio, 14.37 (95% confidence interval [CI], 7.69-26.84) for the first day after recurrent MI and 5.42 (95% CI, 2.88-10.22) for the first day after bleeding. Thereafter the risk of subsequent mortality gradually decreased but remained elevated long after a recurrent MI (hazard ratio, 4.95 [95% CI, 3.27-7.48] between 1 day and 1 year after recurrent MI and hazard ratio, 2.56 [95% CI, 1.56-4.21] beyond 1 year after recurrent MI), but decreased to nonsignificant level beyond 1 month after the bleeding (hazard ratio, 0.56 [95% CI, 0.27-1.14]).

Conclusions: The occurrence of both recurrent MI and bleeding in the first year after ST-segment-elevation MI is associated with subsequent mortality. The risk implication of recurrent MI, however, was greater and more sustained over time than that of severe bleeding.