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A positive family history (FHx+) of coronary artery disease (CAD) is a well-known risk factor for the development of coronary pathology in first-degree relatives. We sought to evaluate the association between FHx+ of CAD and clinical outcomes in patients presenting with a first ST-elevation myocardial infarction (STEMI).A historical cohort study of all patients with a first STEMI, who were admitted to cardiac ICU between 2007 and 2016, was carried out. Univariate and multivariate analyses were carried out to compare patients with or without a FHx+ of CAD. In further analysis, propensity score matching was used to reduce differences in baseline characteristics.The study included 1785 patients, 365 (20%) of whom had FHx+ of CAD. FHx+ was associated with decreased in-hospital major adverse events and long-term mortality rates (hazard ratio=0.208, 95% confidence interval: 0.051–0.857; P=0.03). After propensity score matching, patients with FHx+ had decreased long-term mortality rates (hazard ratio=0.105, 95% confidence interval: 0.033–0.33; P<0.001).In this large cohort of patients with STEMI, FHx+ was associated with better short-term and long-term outcomes. Understanding the rule of FHx in patients with STEMI is important to evaluate the prognosis and may help to construct a prediction model for patients admitted to cardiac ICU.