Journal of General and Family Medicine 2016, vol. 17, no. 4, p. 332–335.

Preliminary Reports

Cause of Death in Patients with Acute Coronary Syndrome

Yuji Nishizaki, MD, Katsumi Miyauchi, MD, Shinya Okazaki, MD,

Hiroshi Tamura, MD, Iwao Okai, MD, Manabu Ogita, MD,
Yoshiteru Kato, MD, Shuta Tsuboi, MD, Hirokazu Konishi, MD,
Ryo Naito, MD, Takeshi Kurata, MD, and Hiroyuki Daida, MD

Department of Cardiology, Juntendo University Graduate School of Medicine

Background: It is important to assess cause of death in patients with acute coronary syndrome (ACS) to improve the
accuracy of prognosis.

Methods: We investigated the cause of death in 221 patients with a first diagnosis of ACS.

Results: In the short-term outcome, the major cause of death was cardiovascular disease (35/50, 70.0%). In the long-
term outcome, non-cardiovascular death was the major cause of death (97/171, 56.7%). The major preventable causes
of death were pneumonia (13/171, 7.6%) and heart failure (19/171, 11.1%).

Conclusions: The major preventable causes of death in patients with ACS are pneumonia and heart failure in the
long-term outcome.

Keywords: acute coronary syndrome, cause of death

Introduction incidence of ACS will inevitably increase in the near

Coronary artery disease (CAD) has been increasing in
recent years because of the aging of the population
and the westernization of lifestyles.1,2 Treatment and
prevention of acute coronary syndrome (ACS) is
imperative because of the lethality of the disease. The
future owing to the rapidly increasing age of the
population. Therefore, more attention should be paid
to the management of patients with ACS. The present
study focused on the causes of death in patients with
ACS.

Corresponding author: Katsumi Miyauchi, MD

Department of Cardiology, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo 113-
8421, Japan
E-Mail: ktmmy@juntendo.ac.jp
Received for publication 5 May 2015 and accepted in revised form 18 August 2015
© 2016 Japan Primary Care Association

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 Cause of Death in Patients with ACS

Table 1. Baseline Clinical Characteristics at Ad- Table 2. Cause of death in patients with acute
mission (n = 221) coronary syndrome
Age (years) « SD 73.4 « 9.7 Cause of Cause of
Male gender, n (%) 158 (71.5) death in the death in the
Coronary risk factors short-term long-term
Current smoking, n (%) 47 (21.3) (n = 50) (n = 171)
Family history of ischemic heart Cardiovascular Death, 35 (70.0) 49 (28.7)
36 (16.3)
disease, n (%) n (%)
Diabetes mellitus, n (%) 90 (40.7) Fatal Myocardial 28 (56.0) 11 (6.4)
Hypertension, n (%) 140 (63.3) Infarction, n (%)
Dyslipidemia, n (%) 117 (52.9) Fatal Stroke, n (%) 1 (2.0) 4 (2.3)
Clinical diagnosis Other Cardiovascular 6 (12.0) 34 (19.9)
Acute myocardial infarction, n (%) 146 (66.1) Death, n (%)
Unstable angina, n (%) 75 (33.9) Heart failure, n (%) 1 (2.0) 19 (11.1)
SD = standard deviation Others, n (%) 5 (10.0) 15 (8.8)
Non-cardiovascular 7 (14.0) 97 (56.7)
Death, n (%)
Pneumonia, n (%) 1 (2.0) 13 (7.6)
Methods Other infection, n (%) 0 5 (2.9)
This was a single-center retrospective observational Cancer, n (%) 2 (4.0) 53 (31.0)
study performed at Juntendo University Hospital Senility, n (%) 1 (2.0) 7 (4.1)
located in the center of Tokyo. We retrospectively Others, n (%) 3 (6.0) 19 (11.1)
investigated the deaths of patients with a first Unknown, n (%) 8 (16.0) 25 (14.6)
diagnosis of ACS who were admitted to our hospital
from January 1997 to December 2011 and underwent
emergency percutaneous coronary intervention (PCI),
as far as we could identify their long-term prognosis. (28/50, 56.0%). In the long-term outcome, non-
We assessed the cause of death in the both short-term cardiovascular death was the major cause of death
(within three months after ACS) and long-term (over (97/171, 56.7%). Most of these non-cardiovascular
three months after ACS) in addition to baseline deaths were caused by cancer or pneumonia, including
clinical characteristics at admission. The cause of aspiration pneumonia (53/171, 31.0%, and 13/171,
death was classified as fatal myocardial infarction 7.6%, respectively). In cardiovascular deaths, HF was
(MI), fatal stroke, other cardiovascular death [heart the major cause of death (19/171, 11.1%).
failure (HF) and others], non-cardiovascular death
(pneumonia, other infection, cancer, senility, and Discussion
others), or unknown. The cause of death was assessed In the present study, we showed that the major causes
from the medical records. This study was approved by of death in patients with ACS were fatal MI in the
the Institutional Ethics Committee of the hospital. short-term follow up. In the long-term follow up, non-
cardiovascular death was the major cause of death.
Results The major preventable causes of death were
We identified 221 patients who had died. Table 1 shows pneumonia and HF. This result may also be applicable
the baseline clinical characteristics at admission. Table 2 to the Japanese general population.
shows the short-term and long-term cause of death. In the The incidence of ACS in Japan has been increasing
short-term outcome, the major cause of death was owing to the westernization of lifestyles and the aging
cardiovascular disease (35/50, 70.0%). Most of these population. The MIYAGI-AMI Registry Study re-
cardiovascular deaths were caused by fatal MI vealed that the overall age-adjusted incidence of acute

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 Journal of General and Family Medicine
MI (per 100,000 people per year) increased from 7.4 in
1979 to 27.0 in 2008, indicating a steadily increasing
trend in acute MI incidence in Japan.2 Therefore, more
attention should be paid to the management of patients
with ACS and the assessment of the cause of death.
Infectious diseases, primarily pneumonia including
aspiration pneumonia, and HF were the main cause of
preventable death in the long-term outcome. Thus,
prevention of pneumonia and HF is a very important
issue. Considering the management of HF and the
prevention of pneumonia together produced two ideas:
the use of angiotensin-converting enzyme inhibitor
(ACE-I) and inoculating ACS patients with both
pneumococcal and influenza vaccine. Administering
ACE-I is reasonable, especially in Asians and patients
who have a medical history of stroke, because ACE-I are
essential to improve the prognosis of heart failure and to
help prevent aspiration pneumonia by increasing
concentrations of bradykinin.3–5 Pneumococcus is a
major pathogenic bacterium that causes community-
acquired pneumonia, and the pneumococcal vaccine is
recommended for elderly patients. Several previous
studies have shown that the influenza vaccine has a
preventive effect on cardiovascular events.6–9
We investigated deaths by HF in the long-term by
classifying the patients into a very elderly patient
group aged ²75 years and a group aged <75 years,
though the results of the investigation were not
described in the Results section in the main text. Of
171 deaths in the long-term, 76 deaths occurred in the
very elderly patient group, among which 12 deaths
were caused by HF (12/76, 15.8%), whereas 95 deaths
occurred in the younger patient group, among which 7
deaths were caused by HF (7/95, 7.4%). This indicated
a higher incidence of death by HF in the very elderly
group. In very elderly patients, standardized
treatments for HF are not always pursued because of
their low toler-ability.10 For example, beta-blockers
are not adminis-tered in cases where bradycardia may
be induced, or ACE-I/ARB are not administered if
there is a possibility of hyperkalemia with chronic
kidney disease.
There are two limitations to the present study. First, it
was a single-center study and did not receive an
external validity evaluation. Second, the duration of
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2016, vol. 17, no. 4
the study was >10 years (1997–2011), and medical
advancements during this long period might have
affected the results of the study. Therefore, multi-
centered prospective studies, focusing on cause of
death in patients with ACS, are required to confirm the
results of the present study.
Conclusion
We should recognize that the major causes of death in
patients with ACS are fatal MI in the short-term
outcome. Considering long-term outcomes,
pneumonia and HF were an important preventable
cause of death. We should pay attention to the
management of these diseases in patients with ACS.
Acknowledgments
This study was supported by a Grant-in-Aid for Scientific
Research (23591063) from the Japan Society for the
Promotion of Science. The authors would also like to
thank Takeshi Asakura for his help in translating this
report into English, and Ms. Yumi Nozawa and Ms.
Ayako Onodera for clinical research assistance.
Disclosures
There are no conflicts of interest.
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