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CVD

History of CVD and Mortality Risks: Single vs Multiple Events

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide. Individuals with established CVD face significant risks of recurrent events and death. This report synthesizes current evidence on mortality risks in patients with a history of CVD, focusing on differences between single and multiple cardiovascular events.

Incidence Rates of Recurrent Events

Research consistently shows high rates of recurrence among patients with established CVD:

  • In a cohort of patients with established CVD, during a median follow-up of 8.9 years, 19.5% experienced one CV event while 17.8% experienced multiple CV events1
  • For patients with acute coronary syndrome (ACS), the 5-year event rate for a composite endpoint (nonfatal MI, nonfatal ischemic stroke, and cardiovascular death) was 33.4%2
  • In a Middle Eastern study, the overall incidence rate of recurrent CVD events was 92.1 per 1000 patient-years, with an 8-year cumulative incidence of 73.7%3

Mortality Risk: Single vs Multiple Events

Single Event Mortality

The mortality risk after a first cardiovascular event varies by event type:

  • For patients with a first acute coronary syndrome, the instantaneous risk is highest immediately after discharge at 40.9%, gradually declining to approximately 6.7% at 1 year2
  • Among patients with a first stroke, mortality rates are substantial but lower than for recurrent strokes4

Multiple Event Mortality

Patients who experience recurrent events face significantly higher mortality risks:

  • Mortality due to recurrent stroke is approximately twice as high as mortality from first stroke4
  • In patients with established CVD, there was a higher proportion of CV death among recurrent events compared to first events (14.5% vs 11.7%)1
  • The risk pattern changes with multiple events, with a higher proportion of certain event types (major adverse limb events increased from 12.4% in first events to 24.2% in recurrent events)1

Time-Dependent Risk Patterns

The risk of recurrent events and death follows specific temporal patterns:

  • Risk is highest immediately following an index event, with a nearly 6-fold higher risk immediately after discharge compared to the period 1+ year after hospitalization2
  • After ACS, the annualized risk is approximately 40.9% immediately after discharge, declining to about 6.4% after 1 year of follow-up2
  • Risk remains stable but elevated after the first year (approximately 6.4% annualized risk)2

Risk Factors for Recurrent Events and Mortality

Several factors significantly increase the risk of recurrent events and mortality:

Strongest Risk Factors (Hazard Ratio >1.5)

  • Age ≥65 years (HR 1.62 for primary endpoint)2
  • Heart failure (HR 1.74 for primary endpoint)2
  • Advanced renal disease (Stages IV-V) (HR 1.58-1.61)2
  • Prior ACS hospitalization within 12 months (HR 1.58)2
  • History of ischemic stroke (HR 1.81-2.00)2
  • Index MI without revascularization (HR 1.81)2
  • Female sex (HR 1.96 in some populations)3
  • Diabetes mellitus3

Moderate Risk Factors (Hazard Ratio 1.2-1.5)

  • Hypertension (HR 1.21)2
  • Chronic obstructive pulmonary disease (HR 1.20)2
  • Atrial fibrillation/flutter (HR 1.21)2
  • Moderate renal disease (Stage III) (HR 1.25)2

Event Type Patterns in Recurrent CVD

The composition of events differs between first and subsequent cardiovascular events:

  • Higher proportion of major adverse limb events in recurrent events (24.2% vs 12.4%)1
  • Higher proportion of CV death in recurrent events (14.5% vs 11.7%)1
  • Lower proportion of non-fatal myocardial infarctions (8.1% vs 11.8%), non-fatal strokes (5.6% vs 9.4%), and revascularization procedures in recurrent events1

Conclusion

Patients with a history of CVD face substantial risks of both recurrent events and mortality. Multiple events carry higher mortality risks than single events, with recurrent stroke mortality approximately double that of first stroke. Risk is highest immediately following an index event and remains elevated compared to the general population even years later.

The evidence supports aggressive secondary prevention measures including both lifestyle modifications and pharmacological therapy for all patients with established CVD, with particular attention to those with the highest-risk profiles: elderly patients, those with heart failure, renal disease, or a recent history of ACS or stroke.

Footnotes

  1. https://pmc.ncbi.nlm.nih.gov/articles/PMC7942272/ ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  2. https://www.ahajournals.org/doi/10.1161/JAHA.121.022198 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8 ↩9 ↩10 ↩11 ↩12 ↩13 ↩14 ↩15

  3. https://d-nb.info/1206089369/34 ↩ ↩2 ↩3

  4. https://pmc.ncbi.nlm.nih.gov/articles/PMC8199949/ ↩ ↩2