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Related Articles. Wearables for Promoting Physical Activity. The committee made its determinations after review of all source documents relating to in-hospital death and myocardial reinfarction.
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Continuous variables are presented as medians and 25th and 75th percentiles, and discrete variables as frequencies and percentages. Only descriptive statistics are presented for the comparison of the baseline characteristics of the 4 ECG groups. Multivariate logistic regression techniques were used to develop a day death model, and a day death or reinfarction model, using the baseline characteristics as candidate predictors. Logistic models were created to determine the effect of the ECG category and elevated CK on admission on day death and day death or reinfarction, after adjusting for the baseline predictors.
The interaction between the ECG category and an elevated CK level was tested to determine whether the effect of the latter was similar across categories. The baseline characteristics of the patients, divided on the basis of the features of their presenting ECG, are shown in Table 1. Patients presenting with ST-segment elevation or ST-segment elevation and depression were more likely to be men and current smokers.
Non-ST Elevation ACS in the Emergency Department
Those with T-wave inversion or ST-segment depression had a higher prevalence of hypercholesterolemia and hypertension, and a longer history of coronary disease, as is shown by a higher prevalence of previous angina, MI, angioplasty, or bypass surgery. Patients with ST-segment elevation or ST-segment elevation and depression were more likely to have single-vessel disease. The patients with ST-segment depression had the worst overall risk profile; they were older and had a worse Killip class, and more of them had diabetes, prior bypass surgery, a history of heart failure, or 3-vessel disease.
The medications and procedures used in the trial are summarized in Table 2. The incidence of the primary end point of death and reinfarction, and of its components, is shown in Table 3. The largest difference in mortality was observed between the group with T-wave inversion and the other groups. The probability of death was highest during the first few days in the 2 groups with ST-segment elevation, but then tended to plateau in the group with ST-segment elevation alone Figure 1 , upper panel.
On the other hand, the probability of early death was lower in the group presenting with ST-segment depression, but tended to increase over time and the mortality rate in this group at 6 months was not different from that of the group with ST-segment elevation plus depression Figure 1 , lower panel.
On admission, an elevated level of CK was found in The day incidences of death and death or reinfarction were greater when the CK level on admission was elevated Table 4 , with an OR of 2. Increased age, a higher Killip class, smoking, a previous MI, peripheral vascular disease, and hypertension were associated with increased day death.
US8688206B2 - Visualization of myocardial infarct size in diagnostic ECG - Google Patents
Increased age, a higher Killip class, increased heart rate, diabetes, peripheral vascular disease, previous angina, and hypertension were associated with increased day death or reinfarction. In comparison with the group with T-wave inversion only, the ORs for death or reinfarction at 30 days were 1. The respective ORs for day death were 2. Although the interaction between the ECG category and an elevated CK level on admission was not significant for either outcome, the impact of elevated CK appeared to be limited to the groups with ST-segment deviation. The present analysis shows that patients with these characteristics continue to manifest a high incidence of death and MI despite state-of-the-art therapy with aspirin, a thrombin inhibitor, thrombolysis, revascularization procedures, or all of these.
Based on our results, the first 2 diagnostic tools available in the emergency department, the ECG and CK determinations, may allow bedside risk stratification and prediction of cardiac events. The ECG was capable of discriminating the risk of developing cardiac events during short- and long-term follow-up. On the other hand, in the patients with ST-segment depression only, the incidence of early events was lower but continued to increase during follow-up, as has been reported in previous studies.
In comparison with patients with ST-segment elevation alone, patients with ST-segment elevation and depression were similar with regard to baseline characteristics, risk factors, and most treatments. Nevertheless, the angiographic data show that they had more severe coronary artery disease.
Acute Myocardial Infarction | SpringerLink
In addition, the present data and a recent study from the Global Utilization of Streptokinase and TPA alteplase for Occluded Coronary Arteries GUSTO-I database 17 show that patients with ST-segment elevation and depression have larger infarctions, as shown by higher peak CK levels, more congestive heart failure symptoms, and worse left ventricular ejection fractions. Thus, in patients presenting with ST-segment elevation, associated ST-segment depression is a marker of worse prognosis, particularly in the long term, perhaps deserving more intensive treatment and follow-up.
The patients with isolated T-wave inversion had a relatively benign prognosis compared with the other groups, particularly in terms of mortality. However, the prevalence of risk factors and previous cardiac events was similar to that of patients with ST-segment depression and, during follow-up, they underwent revascularization procedures at a rate similar to that of the groups with a worse prognosis. In this large multicenter trial, we used a simple classification of the presenting ECG, suitable to be used by any physician in the emergency department; this qualitative classification allows an immediate stratification of the risk over time of death and reinfarction.
Although it was not the intent of the current analysis, possibly a more sophisticated gradation of risk could be determined within each ECG category by accounting for the magnitude and location of ST-segment shift and T-wave inversion. The prognostic importance of myocardial necrosis is well-known and has been recently confirmed across the spectrum of acute coronary syndromes. However, even among patients who had evolving acute MI with CK elevation during the first 16 hours, CK levels at presentation were elevated in only a minority.
The CK elevation at presentation was associated with a worse prognosis, especially among patients with ST-segment shifts. Further investigation is warranted to determine the reason for worse outcomes with CK elevation at presentation even among patients with ST-segment elevation. A worse outcome in patients with myocardial damage has been shown in smaller studies of more sensitive biochemical markers of myocyte injury, such as troponin T, 24 - 26 troponin I, 27 and myosin light chains.
In conclusion, this study demonstrates that the ECG result and CK level on admission can identify a difference in mortality between 1. The simple stratification model offered by the 2 diagnostic tools most widely available at the time of hospital admission may be extremely useful for more effective targeting of intervention trials in acute coronary syndromes. All Rights Reserved.
Top, mortality rate up to 30 days. Bottom, mortality rate to 6 months. Table 1. Table 2. Table 3. Acute cerebrovascular events, especially hemorrhage, may present with diffuse precordial T wave inversions due to small vessel ischemia The ECG is the first clinical tool that allowed assessment of myocardial ischaemia and despite multiple paradigm shifts in the management of ACS, it continues to be the pre-eminent test directing therapeutic management and prognostic stratification.
Conflict of interest: none declared.
References: 1. Alpert, Allan S. Jaffe, Maarten L.
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