The criteria for a diagnosis of ACS are based on the clinical presentation and electrocardiography, as well as the presence of biochemical markers of necrosis in the patientРІР‚в„ўs serum ( 15, 16). The aims of the ABC Study were ( 1) long-term follow-up with regard to both fatal and non-fatal events, and ( 2) evaluation of the prognostic value of several clinical variables at baseline. Specifically, the study includes all consecutive Caucasian patients admitted between June 1995 and January 1998 to intensive care units at three general hospitals in ItalyРІР‚в„ўs Veneto region for unstable angina, non-ST elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI). It was designed to investigate an unbiased ACS patient population. The ABC Study on Heart Disease ( is an on-going prospective study. In this study of the same region, we aimed to investigate the existence of differences in cancer mortality among unselected patients who survived the index hospitalization for ACS and were followed for 22 years.

We have observed that cancer risk in patients long after ACS significantly differs based on the geographic distribution in six urban and rural areas in the Veneto region in northern Italy, with the highest observed risk in northern rural areas ( 14).

Our group also reported a higher incidence of cancer and neoplastic mortality in patientsРІР‚в„ў post-MI compared to the general population ( 4). In another large general cohort study (28,763 participants) with prospective design and 16 years of follow-up, patients who developed MI had a 46% higher hazard ratio of cancer compared to subjects without MI (multivariable-adjusted HR 1.46 95% CI: 1.21РІР‚вЂњ1.77) ( 13). The study showed that MI was associated with an increased risk of overall cancer compared to the reference population (adjusted IRR 1.14, 95% CI 1.10РІР‚вЂњ1.19) ( 12). Moreover, the incidence rates of cancer and death were evaluated in participants with myocardial infarction (MI) from Danish registries which examined 2,871,168 individuals. The SHIP (Sakakibara Health Integrative Profile) cohort study that enrolled a total of 32095 participants with cardiovascular diseases showed that cancer incidence and mortality were >2РІР‚С’fold higher in patients with atherosclerotic cardiovascular disease (including coronary artery diseases) than in patients with nonatherosclerotic cardiovascular diseases ( 11). Modifiable risk factors such as tobacco smoking, a sedentary lifestyle, unhealthy diet, and obesity are reported to be major contributors to the pathogenesis of both diseases, possibly reflecting a shared biology ( 3РІР‚вЂњ 7).Р”Р„n increased risk of malignancy and cancer death was recently reported after acute coronary syndrome (ACS) ( 4, 8РІР‚вЂњ 10) and several epidemiological studies presented the higher risk of incident cancer in patients with cardiovascular diseases, especially CAD. The diseases are linked by inflammation and oxidative stress, which contribute to the development and progression of both. Heart disease, especially ischemic heart diseases, and malignancy are considered the major two causes of death worldwide ( 1, 2). We did not observe an urban/rural difference in non-neoplastic death risk or a significant interaction between the geographic areas. Interestingly, these results persisted, and even strengthened, after exclusion of the 22 patients who developed malignancy and survived to the end of follow-up. The fully adjusted Cox regression and Fine-Gray competing risk regression models provided similar results. Geographic areas, however, showed a strong positive interaction, with risk increasing from the urban to rural areas from southern to northern provinces (HR 1.9 95% CI 1.1РІР‚вЂњ3.0 p = 0.01). No difference in the cancer death risk was found between the urban and rural areas or between southern and northern provinces (hazard ratio 1.1 95% confidence interval 0.7РІР‚вЂњ1.7 p = 0.59 and HR 1.1 95% CI 0.9РІР‚вЂњ1.4 p = 0.29, respectively) according to the unadjusted Cox regression analysis.

Pre-existing malignancy was noted in 15 patients, whereas 106 patients developed cancer during the follow-up period, which represented 6232 person-years.

Urban (46%) and rural (54%) residents shared most of their baseline demographic and clinical characteristics. With 3 exceptions, all patients completed the 22-year follow-up or were followed until death.

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