In Reply: Our study challenges conventional wisdom that patients with more coronary heart disease (CHD) risk factors have worse outcomes following their first MI. We found that patients with multiple CHD risk factors presented much earlier in life with MI and had lower hospital mortality than patients with fewer or no risk factors. We confirmed that the high prevalence of risk factor exposure in patients with MI was consistent with the prior literature.
Dr Santulli seeks additional information that may enhance our study, such as the influence of a dose-dependent effect of CHD risk factors, presence of the metabolic syndrome, other novel risk markers, and infarct size. Unfortunately, these factors were not available in the National Registry of Myocardial Infarction. Although baseline infarct size was not recorded, the finding of an inverse relationship between the number of CHD risk factors and mortality was consistently observed among patients with low-, intermediate-, and high-risk features using 2 well-validated measures of infarct severity (Killip classification and TIMI Risk Index).