Impact of Missed Outpatient Follow-Up on 1-Year Major Adverse Cardiovascular Events in Low-Risk STEMI Patients under a Shared-Care System: A Retrospective Nested Matched Case-Control Study
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Abstract
BACKGROUND: ST-elevation myocardial infarction (STEMI) patients with a preserved left ventricular ejection fraction (LVEF≥50%) after primary percutaneous coronary intervention (PCI) are generally considered low-risk; however, major adverse cardiovascular events (MACE) still occur in 10–15% within the first year. In Thailand's Shared-Care system, post-STEMI patients transferred from tertiary to secondary hospitals for follow-up may experience care gaps, with missed appointments representing an unrecognized system-level risk signal.
OBJECTIVES: To evaluate the association between missed outpatient follow-up exceeding 60 days and 1-year MACE in STEMI patients with preserved LVEF under a Thai Shared-Care system.
METHODS: This retrospective, nested, matched case-control study was conducted at Pattaya Bhattamakun Hospital, Chonburi, Thailand (2020–2025). Cases experienced a MACE composite endpoint (cardiovascular death, nonfatal MI, ischemic stroke, unplanned revascularization, heart failure hospitalization) within 365 days post-discharge. Controls were matched by gender and age (±5 years) at variable ratios (1:7–1:10) and analyzed with exact conditional logistic regression. Two multivariable models were constructed: Model 1 (adjusted for diabetes mellitus and IV furosemide within 24 hours, used as a proxy for Killip class) and Model 2 (adjusted for diabetes mellitus).
RESULTS: The matched analysis included 100 patients (10 cases, 90 controls) from a cohort with an overall MACE incidence of 4.9%. Missed follow-up for >60 days was significantly associated with MACE in univariable analysis (OR=8.66, 95% CI: 1.67–44.93, p=0.01) and remained significant after multivariable adjustment (aOR=10.37, 95% CI: 1.75–61.60, p=0.01). Diabetes mellitus was an independent risk factor (aOR=7.08, 95% CI: 1.39–36.13, p=0.02). Complete revascularization within 45 days was protective only in univariable analysis (OR=0.18, 95% CI: 0.05–0.67, p=0.01).
CONCLUSIONS: Missed follow-up in a Shared-Care setting is significantly associated with 1-year MACE in STEMI patients with preserved LVEF. This system-level indicator may support post-STEMI risk stratification and proactive follow-up interventions.
Thaiclinicaltrials.org number, TCTR20260407003
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References
Del Buono MG, Garmendia CM, Seropian IM, Gonzalez G, Berrocal DH, Biondi-Zoccai G, et al. Heart failure after ST-elevation myocardial infarction: beyond left ventricular adverse remodeling. Curr Probl Cardiol [Internet]. 2023 [cited 2025 Sep 12];48(8):101215. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0146280622001128?via%3Dihub
Hausenloy DJ, Botker HE, Engstrom T, Erlinge D, Heusch G, Ibanez B, et al. Targeting reperfusion injury in patients with ST-segment elevation myocardial infarction: trials and tribulations. Eur Heart J 2017;38:935-41.
Dauw J, Martens P, Deferm S, Bertrand P, Nijst P, Hermans L, et al. Left ventricular function recovery after ST-elevation myocardial infarction: correlates and outcomes. Clin Res Cardiol 2021;110:1504-15.
Otero-García O, Cid-Álvarez AB, Juskova M, Álvarez-Álvarez B, Tasende-Rey P, Gude-Sampedro F, et al. Prognostic impact of left ventricular ejection fraction recovery in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: analysis of an 11-year all-comers registry. Eur Heart J Acute Cardiovasc Care 2021;10:898-908.
Kim YH, Her AY, Rha SW, Choi CU, Choi BG, Park S, et al. Comparison of outcomes between st-segment elevation and non-ST-segment elevation myocardial infarctions based on left ventricular ejection fraction. J Clin Med [Internet]. 2024 [cited 2025 Sep 12];13(22):6744. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11595183/pdf/jcm-13-06744.pdf
Reindl M, Stiermaier T, Lechner I, Tiller C, Holzknecht M, Mayr A, et al. Cardiac magnetic resonance imaging improves prognostic stratification of patients with ST-elevation myocardial infarction and preserved ejection fraction. Eur Heart J Open [Internet] 2021 [cited 2025 Sep 12];1(3):oeab033. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9263884/pdf/oeab033.pdf
Kinlay S, Quach L, Cormack J, Morgenstern N, Hou Y, Young M, et al. Premature discontinuation of dual antiplatelet therapy after coronary stenting in veterans: characteristics and long-term outcomes. J Am Heart Assoc [Internet]. 2021 [cited 2026 Apr 27];10(9):e018481. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8200740/pdf/JAH3-10-e018481.pdf
Alkofide H, Alshuhayb R, Alhazmi N, Almofada R, Bin Hazzaa A, Alsharif A, et al. Adherence to prescribing guideline-directed medical therapy at hospital discharge in subjects with acute coronary syndrome, and the relationship with mortality. Cureus [Intenet]. 2022 [cited 2026 Apr 27];14(4):e24000. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9086652/pdf/cureus-0014-00000024000.pdf
Dizdarevic-Bostandzic A, Begovic E, Burekovic A, Velija-Asimi Z, Godinjak A, Karlovic V. Cardiovascular risk factors in patients with poorly controlled diabetes mellitus. Med Arch 2018;72:13-6.
McQueenie R, Ellis DA, McConnachie A, Wilson P, Williamson AE. Morbidity, mortality and missed appointments in healthcare: a national retrospective data linkage study. BMC Med [Internet]. 2019 [cited 2025 Sep 12];17(1):2. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6329132/pdf/12916_2018_Article_1234.pdf
Huber CA, Meyer MR, Steffel J, Blozik E, Reich O, Rosemann T. Post-myocardial Infarction (MI) care: medication adherence for secondary prevention after MI in a large real-world population. Clin Ther 2019;41:107-17.
Rao SV, O'Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: a report of the American college of cardiology/American heart association joint committee on clinical practice guidelines. Circulation [Interner]. 2025 [cited 2026 Apr 27];151(13):e771-e862. Available from: https://www.ahajournals.org/doi/epdf/10.1161/CIR.0000000000001309
Schlesselman JJ. Case-control studies : design, conduct, analysis. New York: Oxford University Press; 1982.
Schulz KF, Grimes DA. Case-control studies: research in reverse. Lancet. 2002;359:431-4.
Pearce N. Analysis of matched case-control studies. BMJ [Internet]. 2016 [cited 2025 Sep 12 ];352:i969. Available from: https://www.bmj.com/content/bmj/352/bmj.i969.full.pdf
Ahmed TAN, Othman AAA, Demitry SR, Elmaghraby KM. Impact of residual coronary lesions on outcomes of myocardial infarction patients with multi-vessel disease. BMC Cardiovasc Disord [Internet] 2024 [cited 2025 Sep 12];24(1):68. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10804526/pdf/12872_2023_Article_3657.pdf
Samir A, Elshinawi M, Yehia H, Farrag A. Predictive utility of residual SYNTAX score for clinical outcomes after successful primary percutaneous coronary intervention. Acta Cardiol 2024;79:761-7.
