The Association of Admission Heart Rate and In-Hospital Cardiovascular Events
The Association of Admission Heart Rate and In-Hospital Cardiovascular Events
Aims To evaluate the relationship between presenting heart rate (HR) and in-hospital events in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS).
Methods and results We evaluated 139 194 patients with NSTE-ACS in the CRUSADE quality improvement initiative. The presenting HR was summarized as 10 beat increments. Patients with systolic BP < 90 mm Hg (4030 patients) were excluded to avoid the confounding effect of cardiogenic shock. An adjusted odds ratio (OR) was calculated using a reference OR = 1 for HR of 60–69 b.p.m. after controlling for baseline variables. Primary outcome was a composite of in-hospital events all-cause mortality, non-fatal re-infarction, and stroke. Secondary outcomes were each of these considered separately. From the cohort of 135 164 patients, 8819 (6.52%) patients had a primary outcome (death/re-infarction or stroke) of which 5271 (3.90%) patients died, 3578 (2.65%) patients had re-infarction, and 1038 (0.77%) patients had a stroke during hospitalization. The relationship between presenting HR and primary outcome, all-cause mortality, and stroke followed a 'J-shaped' curve with an increased event rate at very low and high HR even after controlling for baseline variables. However, there was no relationship between presenting HR and risk of re-infarction.
Conclusion In contrast to patients with stable CAD, in the acute setting, the relationship between presenting HR and in-hospital cardiovascular outcomes has a 'J-shaped' curve (higher event rates at very low and high HRs). These associations should be considered in ACS prognostic models.
The significance of patient's heart rate (HR) has been considered in various prognostic models. In patients with established CAD, a direct linear relationship has been shown between HR and long-term cardiovascular events such that lower the HR better is the prognosis. Similarly, standard ACS risk models such as the PURSUIT and GRACE risk models have included admission HR as a prognostic factor, modelled as a linear function. For example, in the GRACE risk prediction model, for every 30 beat increase in HR, the risk of events increased by 30% (adjusted hazard ratio = 1.30; 95% CI = 1.23–1.47). Despite this, there are limited data on the true association of HR and outcomes in those with ACS in community practice.
The objective of the present study was to evaluate the relationship between presenting HR and in-hospital cardiovascular events in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). This analysis used the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative database.
Abstract and Introduction
Abstract
Aims To evaluate the relationship between presenting heart rate (HR) and in-hospital events in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS).
Methods and results We evaluated 139 194 patients with NSTE-ACS in the CRUSADE quality improvement initiative. The presenting HR was summarized as 10 beat increments. Patients with systolic BP < 90 mm Hg (4030 patients) were excluded to avoid the confounding effect of cardiogenic shock. An adjusted odds ratio (OR) was calculated using a reference OR = 1 for HR of 60–69 b.p.m. after controlling for baseline variables. Primary outcome was a composite of in-hospital events all-cause mortality, non-fatal re-infarction, and stroke. Secondary outcomes were each of these considered separately. From the cohort of 135 164 patients, 8819 (6.52%) patients had a primary outcome (death/re-infarction or stroke) of which 5271 (3.90%) patients died, 3578 (2.65%) patients had re-infarction, and 1038 (0.77%) patients had a stroke during hospitalization. The relationship between presenting HR and primary outcome, all-cause mortality, and stroke followed a 'J-shaped' curve with an increased event rate at very low and high HR even after controlling for baseline variables. However, there was no relationship between presenting HR and risk of re-infarction.
Conclusion In contrast to patients with stable CAD, in the acute setting, the relationship between presenting HR and in-hospital cardiovascular outcomes has a 'J-shaped' curve (higher event rates at very low and high HRs). These associations should be considered in ACS prognostic models.
Introduction
The significance of patient's heart rate (HR) has been considered in various prognostic models. In patients with established CAD, a direct linear relationship has been shown between HR and long-term cardiovascular events such that lower the HR better is the prognosis. Similarly, standard ACS risk models such as the PURSUIT and GRACE risk models have included admission HR as a prognostic factor, modelled as a linear function. For example, in the GRACE risk prediction model, for every 30 beat increase in HR, the risk of events increased by 30% (adjusted hazard ratio = 1.30; 95% CI = 1.23–1.47). Despite this, there are limited data on the true association of HR and outcomes in those with ACS in community practice.
The objective of the present study was to evaluate the relationship between presenting HR and in-hospital cardiovascular events in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). This analysis used the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative database.
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