1Universitätsklinikum Heidelberg Klinik für Innere Med. III, Kardiologie, Angiologie u. Pneumologie Heidelberg, Deutschland
The impact of cancer on the mortality of patients with acute coronary syndrome (ACS) is still unclear. We analyzed 1,481 patients who were subjected to cardiac catherization from 01/2006 to 12/2017 at University Hospital Heidelberg due to acute coronary syndrome. 441 patients with initial diagnosis of cancer prior to ACS were identified. The most prevalent cancer entities were gastrointestinal tumors (16%), prostate cancer (12%), basal cell carcinoma (12%) and breast cancer (8%). We compared these patients to non-cancer ACS patients via propensity score matching according to the cardiac risk factors age, sex, arterial hypertension (aHT) and diabetes.
All-cause mortality (ACM) was higher in oncological ACS patients (5-year ACM: 148 deaths (33.6%) in non-cancer vs. 243 deaths (55.1%) in cancer patients, p < 0.001, chi-square test). Cancer patients with Non-ST-elevation myocardial infarction (NSTEMI) showed the highest 5-year ACM (88 non-cancer patients (40%) vs. 174 cancer patients (64.9%), p < 0.001, chi-square test). In multivariant logistic COX models, we found a similar predictive value for 5-year ACM regarding age > 65 years (non-cancer HR:4.75 p=0.002, cancer HR:2.07 p=0.018), heart failure with reduced ejection fraction (HFrEF) (non-cancer HR:6.1 p=0.002, cancer HR:2.26 p=0.005) and chronic obstructive pulmonary disease (COPD) (non-cancer HR 2.57 p<0.001, cancer HR:1.51 p=0.022) in cancer and non-cancer patients. STEMI (non-cancer HR:4.84 p=0.01, cancer HR:1.43 p=0.25) and diabetes (non-cancer HR:1.47 p=0.03, cancer HR:1.28 p=0.1), showed a predictive value only in non-cancer patients, whereas prior stroke (non-cancer HR:1.14 p=0.68, cancer HR:1.73 p=0.004) only in cancer patients. Time-dependent Kaplan-Meier analyses showed a pronounced drop in survival in the first one to two years regarding age, HFrEF and COPD in cancer and non-cancer patients. Neither the degree of the coronary lesions nor cardiac biomarker elevations (hs-cTnT and NT-proBNP) were able to discriminate survival in this patient cohort. The higher mortality in NSTEMI patients correlated with a higher occurrence of cardiovascular risk factors and co-morbidities such as diabetes, cardiomyopathy, stroke, prior coronary artery disease (CAD), COPD or atrial fibrillation (AF) compared to the other ACS patients including STEMI. This distribution was comparable between non-cancer and cancer patients, indicating a relevant effect of cancer as an additional risk factor for mortality in ACS patients.
Our data support the notion, that the combined occurrence of ACS and cancer has an additive influence on mortality. In addition, cardiovascular co-morbidities have a comparable predictive value for mortality in cancer patients. This leads to the conclusion that cancer patients, also in terms of acute cardiac events, could benefit from improved cardiac care.