Circulation, Vol 85, 1254-1264, Copyright © 1992 by American Heart Association
HS Mueller, LS Cohen, E Braunwald, S Forman, F Feit, A Ross, M Schweiger, H Cabin, R Davison and D Miller
BACKGROUND. Thrombolysis has altered treatment of acute myocardial
infarction (AMI). Therefore, reevaluation of predictors of outcome and
treatment strategies is appropriate. METHODS AND RESULTS. Clinical
variables collected prospectively for the 3,339 patients of the
Thrombolysis in Myocardial Infarction II study were analyzed
retrospectively to identify predictors of clinical events at 42 days and
earlier and to identify subgroups in which an invasive or conservative
strategy might be superior. Pulmonary edema/cardiogenic shock presented as
the strongest independent correlate with death (relative risk, 6.0). In two
subgroups, mortality differed between the invasive and conservative
strategies: 1) Patients with versus without prior AMI had a higher
mortality in the conservative strategy (11.5% versus 3.5%, p less than
0.001); in the invasive strategy, the mortality rates were similar (6.0%
and 5.1%). 2) Patients with diabetes mellitus and no prior AMI had a higher
mortality in the invasive than in the conservative strategy (14.8% versus
4.2%, p less than 0.001). Reinfarction was not independently correlated
with baseline characteristics except with history of angina (relative risk,
1.9). Mortality was lower in current smokers and ex-smokers versus never-
smokers (3.6% and 4.8% versus 8.0%, p less than 0.001). Current smokers had
a lower risk profile (p less than 0.001), including age, pulmonary
edema/cardiogenic shock, history of hypertension, and diabetes. The rate of
reinfarction was lower in current smokers versus ex-smokers and
never-smokers (4.6% versus 8.3% and 8.8%, p less than 0.001). "Not current
smoker" was an independent correlate with reinfarction (relative risk,
1.9). The coronary anatomy did not differ among the current smokers,
ex-smokers, and never-smokers. CONCLUSIONS. The strong independent
correlation of pulmonary edema/cardiogenic shock with death suggests that
thrombolysis is not sufficient to improve survival in these patients. The
higher mortality in patients with versus without prior AMI in the
conservative strategy suggests that early catheterization and
revascularization of these patients might be beneficial. Conversely, the
higher mortality in diabetes without prior AMI in the invasive than in the
conservative strategy suggests that early aggressive management might not
be suitable in this subgroup except for clinical indications. Reinfarction
was not predictable by clinical variables except by history of angina. The
finding that "not current smoker" was an independent correlate with
reinfarction was unexpected.
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Maryland Medical Research Institute, Baltimore, Md. 21210.
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