Determinants and prognostic impact of heart failure complicating acute coronary syndromes observations from The Global Registry of Acute Coronary Events (GRACE)

Background - Few data are available on the impact of heart failure (HF) across all types of acute coronary syndromes (ACS). Methods and Results - The Global Registry of Acute Coronary Events ( GRACE) is a prospective study of patients hospitalized with ACS. Data from 16 166 patients were analyzed: 13 707 patients without prior HF or cardiogenic shock at presentation were identified. Of these, 1778 (13%) had an admission diagnosis of HF (Killip class II or III). HF on admission was associated with a marked increase in mortality rates during hospitalization (12.0% versus 2.9% [ with versus without HF], P < 0.0001) and at 6 months after discharge (8.5% versus 2.8%, P < 0.0001). Of note, HF increased mortality rates in patients with unstable angina ( defined as ACS with normal biochemical markers of necrosis; mortality rates: 6.7% with versus 1.6% without HF at admission, P < 0.0001). By logistic regression analysis, admission HF was an independent predictor of hospital death ( odds ratio, 2.2; P < 0.0001). Admission HF was associated with longer hospital stay and higher readmission rates. Patients with HF had lower rates of catheterization and percutaneous cardiac intervention, and fewer received beta-blockers and statins. Hospital development of HF ( versus HF on presentation) was associated with an even higher in-hospital mortality rate (17.8% versus 12.0%, P < 0.0001). In patients with HF, in-hospital revascularization was associated with lower 6-month death rates (14.0% versus 23.7%, P < 0.0001; adjusted hazard ratio, 0.5; 95% CI, 0.37 to 0.68, P < 0.0001). Conclusions - In this observational registry, heart failure was associated with reduced hospital and 6-month survival across all ACS subsets, including patients with normal markers of necrosis. More aggressive treatment of these patients may be warranted to improve prognosis.