Myocardial infarction: living alone increased the risk of a recurrent cardiac event.

Clinical bottom line (level 2b)

  1. Patients who had a myocardial infarction were at an increased risk of a recurrent cardiac event within 12 months if they: lived alone, had a New York Heart Association class II-IV, had a left ventricular ejection fraction less than 0.40, had less than 12 years of education or were not using beta-blockers.
Case et al: Journal of the American Medical Association 1992; 267 (4): 515-519
Expires March 2003

The study

Prospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: multicentre, USA and Canada

1234 patients (aged mean 60 years, 79% male) enzyme-documented acute myocardial infarction enrolled in the placebo arm of an RCT of diltiazem vs placebo

Excluded if
  • not enrolled within 3 to 15 days after infarction
  • not discharged alive from coronary care unit
  • <25 and >75 years old



    • Factors studied:
  • recurrent cardiac event
  • living alone
  • New York Heart Association class II-IV
  • left ventricular ejection fraction <0.40
  • duration of education <12 years
  • no beta-blockers


    • Placebo arm of diltiazem trial.

    A Cox proportional hazards regression model was used to adjust for confounding factors.

    97% followed with a mean of 25 months, minimum followed for 12 months
    Outcomes studied:
  • recurrent cardiac event

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    recurrent cardiac event 12 months 226/1234 18.3%
    (16.2% to 20.5%)

    prognostic factor for
    recurrent cardiac event     		time to outcome control rate (%) adjusted OR
    (95% CI)    		 NNF+
    (95% CI)
    living alone 12 months 117/993
    (11.8%)     		1.54
    (1.04 to 2.29)     		19
    (9 to 241)
    New York Heart Association class II-IV 12 months 114/1013
    (11.3%)     		1.85
    (1.21 to 2.81)     		13
    (7 to 49)
    left ventricular ejection fraction <0.40 12 months 73/758
    (9.63%)     		1.76
    (1.24 to 2.50)     		16
    (9 to 49)
    duration of education <12 years 12 months 86/728
    (11.8%)     		1.59
    (1.09 to 2.23)     		17
    (9 to 108)
    no beta-blockers 12 months 63/633
    (9.95%)     		1.56
    (1.09 to 2.23)     		21
    (10 to 125)

    Citation

    1. Case RB, Moss AJ, Case N, et al: Living alone after myocardial infarction: Impact on prognosis. Journal of the American Medical Association 1992; 267 (4): 515-519
    Contributor: Clare Wotton and Bob Phillips, January 2000
    Reviewer:

    Clinical Question.
    Patient myocardial infarction
    Intervention or Exposure living alone
    Comparison not living alone
    Outcome subsequent major cardiac event