The prevalence and outcome of hypertension in patients with acute coronary syndrome in six Middle-Eastern countries

Figures & data

Table I. Clinical characteristics and risk factors for acute coronary syndrome.

	HTN (n = 4039)	Non-HTN (n = 4132)	p-value
Age (mean±SD)	59.2 ± 11.6	53.1 ± 12.4	<0.001
Females, %	34	14.4	<0.001
Prior angina pectoris, %	53	28	<0.001
Prior myocardial infarction, %	32.2	16.8	<0.001
Prior CABG, %	8.6	2.7	<0.001
Prior PCI, %	16.8	6.7	<0.001
Family history of CAD, %	13.6	13.5	0.87
Diabetes mellitus, %	55.8	25.4	<0.001
Smoking, %	23.5	38.6	<0.001
Dyslipidemia, %	48.6	15.5	<0.001
Stroke, %	7.8	1.5	<0.001
Chronic obstructive pulmonary disease, %	3.7	6.9	<0.001
Prior aspirin use, %	57.4	24.4	<0.001
Peripheral vascular disease, %	1	3.4	<0.001
Dialysis, %	1.8	0.2	<0.001
Heart rate (mean, beats/min)	87 ± 23	84 ± 22	<0.001
SBP (mean, mmHg)	147 ± 33	132 ± 26	<0.001
DBP (mean, mmHg)	86 ± 19	81.1 ± 17	<0.001
BMI (mean)	28 ± 6	26 ± 5	<0.001
Ischemic chest pain, %	74.2	84.4	<0.001
Atypical chest pain, %	6.7	6.4	<0.001
Dyspnea, %	14.2	5.5	<0.001
Killip class >I, %	28	15.8	<0.001
GRACE risk scoring
Low, n (%)	1012 (32.6)	1495 (45.7)	<0.001
Medium, n (%)	881 (28.4)	955 (29.2)
High, n (%)	1211 (39)	820 (25.1)
Lab. findings
First blood sugar (mg/dl)	11.1 ± 12.1	9.7 ± 10.8	<0.001
Fasting blood sugar (mg/dl)	8.2 ± 8.3	7.2 ± 7.1	<0.001
Peak troponin (ng/ml)	10.3 ± 40.6	22 ± 145	<0.001
First creatinine (μmol/l)	103.5 ± 112.6	82.3 ± 69.3	<0.001
Total cholesterol	4.5 ± 2.5	4.7 ± 2.9	<0.001
HDL(μmol/l)	1.3 ± 3.9	1.33 ± 3.6	0.715
LDL(μmol/l)	3.7 ± 9.6	4.0 ± 9	0.355
Fasting triglyceride (μmol/l)	2.4 ± 8.7	2.7 ± 8.9	0.03
First hemoglobin(mean,gm/l)	14.35 ± 11.8	14.99 ± 10.6	0.009
LV ejection fraction (%)
<40%, n (%)	891 (32.7)	816 (28.2)	<0.001

HTN, hypertension; CABG, coronary artery bypass graft; PCI; percutaneous coronary interventions, CAD; coronary artery disease, SBP; systolic blood pressure, DBP; diastolic blood pressure. GRACE; Global registry of acute coronary events; HDL, high-density lipoprotein; LDL, low-density lipoprotein; LV, left ventricular.

Table II. Management of patients with acute coronary syndrome (ACS) with and without hypertension (HTN).

	HTN	Non-HTN	p-value
On-admission medications
Door to needle (median, IQR), min	45.9 ± 142.5	63 ± 176.6	0.004
Thrombolysis, %	54	60.2	<0.001
Aspirin, %	97.4	98.3	0.008
Clopidogrel, %	52.2	54.5	0.03
Heparin, %	40.5	54.3	<0.001
LMW-heparin, %	52.7	40.9	<0.001
Gp IIb/IIIa inhibitor, %	10.4	11.1	0.3
Beta-blocker, %	64.9	65.3	0.7
ACE, %	67.7	59.6	<0.001
ARB, %	8.3	1.5	<0.001
Primary PCI, %	19.1	19.9	0.5
Facilitated PCI, %	2.6	3.4	0.01
Discharge medications
Aspirin, n (%)	93.6	94.1	0.3
Clopidogrel, n (%)	48.8	51.2	0.2
Statin, n (%)	82.0	79.5	0.004
ACE/ARB, n (%)	69.5	67.8	0.1
Beta-blocker, n (%)	73.8	76.2	0.01
Diuretics, n (%)	33.6	16	<0.001

LMW-heparin, low molecular weight heparin; Gp IIb/IIIa inhibitor, glycoprotein IIb/IIIa inhibitor; ACE, angiotensin-converting enzyme inhibitors; ARB, angiotensin receptor blockers; PCI, percutaneous coronary interventions.

Figure 1. In-hospital mortality in hypertension (HTN) versus non-HTN stratified according to acute coronary syndrome (ACS) diagnosis [ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) or unstable angina].

Figure 2. Predictors of in-hospital heart failure in patients with acute coronary syndrome (ACS); STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation ACS.

Table III. In-hospital clinical outcomes.

	HTN (n = 4036)	Non-HTN (n = 4129)	p-value
In-hospital death, %	3.7	3.4	0.5
Heart failure, %	19.7	12.9	<0.001
Recurrent ischemia, %	10.2	8.9	0.05
Re-infarction, %	2.3	2.6	0.4
Cardiogenic shock, %	5.3	4.9	0.4
Major bleeding, %	0.8	0.6	0.2
Stroke, %	0.6	0.8	0.1
Hospital stay (mean) (days)	5.5 ± 5	5.57 ± 4.1	0.1
STEMI	(n = 1067)	(n = 2133)
In-hospital death, %	9.2	4.7	<0.001
Heart failure, %	23.8	13.8	<0.001
Recurrent ischemia, %	12.2	8.4	0.001
Re-infarction, %	4.1	2.5	0.014
Cardiogenic shock, %	13	7.3	<0.001
Major bleeding, %	1.6	0.8	0.055
Stroke, %	1.8	0.8	0.013
NSTEMI	(n = 1523)	(n = 1107)
In-hospital death, %	2.6	2.5	0.9
Heart failure, %	20.3	11.8	<0.001
Recurrent ischemia, %	10.4	10.5	0.9
Re-infarction, %	3.2	3.3	0.9
Cardiogenic shock, %	3.5	2.9	0.3
Major bleeding, %	0.7	0.5	0.4
Stroke, %	0.7	0.4	0.3
Unstable angina	(n = 1448)	(n = 892)
In-hospital death, %	0.9	1.5	0.2
Heart failure, %	15.9	12	0.009
Recurrent ischemia, %	8.5	8.1	0.7
Re-infarction, %	0.8	0.7	0.8
Cardiogenic shock, %	1.3	1.7	0.4
Major bleeding, %	0.5	0.2	0.3
Stroke, %	0.3	0.2	0.8

HTN, hypertension; STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction.

Table IV. Reported studies of hypertension (HTN) and acute coronary syndrome.

Author/year/origin (ref.)	Study design	No of patients	Prev. HTN (%)	Follow-up	Outcome
Majahalme et al./ 2003/USA (13)	Registry	890	64.4%	Long-term	• Adverse events were equivalent in HTN and non-HTN patients
Ivanuša et al./2008/Croatia (28)	Retrospective/registry	436	47.2%	In-hospital	• HTN patients with AMI had better in-hospital outcome than normotensive patient
Kang et al./2009/Korea (12)	Registry	8568	48.5%	Long-term	• HTN at the time of AMI is associated with ↑ in-hospital mortality
					• Antecedent HTN was not significantly associated with higher mortality
Thune et al./2008/USA (30)	Registry	14,703	53.8%	Long-term	• Antecedent HTN independently increased heart failure and death complications in high risk AMI
					• 6-months after a high-risk MI, elevated systolic blood pressure, a potentially modifiable risk factor, is associated with an increased risk of subsequent stroke and cardiovascular events
Dumaine et al./2006/USA (20)	Randomized trials (pos-hoc analysis)	15,414	71.3%	Long-term	• HTN was independent marker for major short- and long-term cardiac adverse outcomes after NST-ACS
Abrignani et al./ 2005/Italy (27)	Registry	4994	27.6%	In-hospital	• HTN patients with first AMI had better in-hospital outcome than age- and gender matched normotensive subjects
Gustafsson et al./ 1998/Denmark (18)	Retrospective/registry	6676	23%	Long-term	• HTN is a moderate risk factor for mortality after MI in patients aged ≤65 years
Irma et al./2004/Denmark (29)	Registry	3326	25%	In-hospital	• After an acute MI, survival rates for patients with and without a history of HTN are identical when contemporary medical therapy is employed
Bener et al./2005/Qatar (23)	Retrospective/registry	5390	37%	In-hospital	• Strong association between HTN and acute MI
Current study/2010	Registry	8171	49.4%	In-hospital	• In-hospital mortality ↑ in HTN with STEMI but not in NSTEMI or unstable angina
					• The incidence of heart failure complications was ↑ among patients with HTN regardless of the ACS type

ACS, acute coronary syndrome; STEMI, ST-elevation myocardial infarction; NSTEMI, Non-ST elevation myocardial infarction; AMI, acute myocardial infarction; ↑, increased.

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