What is the mortality risk of Non-ST-Elevation Myocardial Infarction (NSTEMI) with simultaneous Cerebrovascular Infarction?

From the Guidelines

The mortality risk for patients experiencing both a non-ST-elevation myocardial infarction (NSTEMI) and a simultaneous cerebrovascular infarct (stroke) is approximately 25-30%. This combined event represents a particularly high-risk scenario as it involves two major organ systems failing concurrently. The mortality risk is significantly higher than either condition alone, with NSTEMI typically carrying a 5-10% in-hospital mortality risk and ischemic stroke approximately 10-20% in the first month 1. Management of these patients is particularly challenging due to competing therapeutic priorities. Antiplatelet and anticoagulation therapies needed for cardiac management may increase bleeding risk in the brain, while withholding these treatments increases cardiac risk.

Some key points to consider in the management of these patients include:

• The importance of a multidisciplinary approach with both cardiology and neurology input
• Careful blood pressure management, typically maintaining systolic BP between 140-180 mmHg in the acute phase
• Individualized antithrombotic therapy based on the size and type of stroke, cardiac risk, and bleeding risk assessment
• The timing of cardiac catheterization, if indicated, must be carefully considered, often being delayed until neurological stability is achieved 1.

It's also worth noting that the use of an invasive strategy, as demonstrated in trials such as FRISC-II and TACTICS-TIMI 18, may be beneficial in high-risk patients with UA/NSTEMI, with a reduction in death or nonfatal MI observed at 6 months and 1 year 1. However, the application of these findings to patients with simultaneous cerebrovascular infarct requires careful consideration of the individual patient's risk factors and clinical presentation.

From the Research

Mortality Risk of NSTEMI plus Simultaneous Cerebrovascular Infarct

• The mortality risk of patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) and simultaneous cerebrovascular infarct is significantly higher compared to those without NSTEMI 2.
• A study using the National Inpatient Sample from 2016 to 2019 found that among patients with acute ischemic stroke, 1.60% had a concomitant NSTEMI diagnosis, and the mortality rate in this group was 14.1% 2.
• In comparison, the mortality rate for patients with acute ischemic stroke without NSTEMI was 3.4% 2.
• The odds ratio for mortality in patients with NSTEMI and acute ischemic stroke was 3.60 (95% CI 3.29 to 3.93, p ≤0.001) 2.
• Other common outcomes in patients with NSTEMI and acute ischemic stroke included acute kidney injury (31.8%), intracranial hemorrhage (6.6%), and sepsis (6.13%) 2.

Percentage of Mortality Risk

• The mortality risk for patients with NSTEMI and simultaneous cerebrovascular infarct is approximately 14.1% 2.
• This is compared to a mortality rate of 3.4% for patients with acute ischemic stroke without NSTEMI 2.
• The increased mortality risk associated with NSTEMI and acute ischemic stroke highlights the need for careful management and treatment of these patients 2.

Treatment and Outcomes

• Percutaneous coronary intervention (PCI) was performed in 9.14% of patients with acute ischemic stroke and NSTEMI 2.
• PCI was associated with reduced mortality (OR 0.35,95% CI 0.23 to 0.54, p <0.001) and intracranial hemorrhage (OR 0.42,95% CI 0.25 to 0.7, p = 0.01) 2.
• The use of antithrombotic therapy, including antiplatelet and anticoagulant agents, is crucial in the management of patients with NSTEMI and acute ischemic stroke 3, 4.