Circulation, Vol 88, 416-429, Copyright © 1993 by American Heart Association
A Volpi, C De Vita, MG Franzosi, E Geraci, AP Maggioni, F Mauri, E Negri, E Santoro, L Tavazzi and G Tognoni
BACKGROUND. Current knowledge of risk assessment in survivors of myocardial
infarction is largely based on data gathered before the advent of
thrombolysis. It must be determined whether and to what extent available
information and proposed criteria of prognostication are applicable in the
thrombolytic era. METHODS AND RESULTS. We reassessed risk prediction in the
10,219 survivors of myocardial infarction with follow-up data available
(ie, 98% of the total) who had been enrolled in the GISSI-2 trial, relying
on a set of prespecified variables. The 3.5% 6-month all-cause mortality
rate of these patients compared with the higher value of 4.6% found in the
corresponding GISSI- 1 cohort, originally allocated to streptokinase
therapy, indicates a 24% reduction in postdischarge 6-month mortality. On
multivariate analysis (Cox model), the following variables were predictors
of 6- month all-cause mortality: ineligibility for exercise test for both
cardiac (relative risk [RR], 3.30; 95% confidence interval [CI], 2.36-
4.62) and noncardiac reasons (RR, 3.28; 95% CI, 2.23-4.72), early left
ventricular failure (RR, 2.41; 95% CI, 1.87-3.09), echocardiographic
evidence of recovery phase left ventricular dysfunction (RR, 2.30; 95% CI,
1.78-2.98), advanced (more than 70 years) age (RR, 1.81; 95% CI,
1.43-2.30), electrical instability (ie, frequent and/or complex ventricular
arrhythmias) (RR, 1.70; 95% CI, 1.32-2.19), late left ventricular failure
(RR, 1.54; 95% CI, 1.17-2.03), previous myocardial infarction (RR, 1.47;
95% CI, 1.14-1.89), and a history of treated hypertension (RR, 1.32; 95%
CI, 1.05-1.65). Early post-myocardial infarction angina, a positive
exercise test, female sex, history of angina, history of insulin-dependent
diabetes, and anterior site of myocardial infarction were not risk
predictors. On further multivariate analysis, performed on 8315 patients
with the echocardiographic indicator of left ventricular dysfunction
available, only previous myocardial infarction was not retained as an
independent risk predictor. CONCLUSIONS. A decline in 6-month mortality of
myocardial infarction survivors, seen within 6 hours of symptom onset, has
been observed in recent years. Ineligibility for exercise test, early left
ventricular failure, and recovery-phase left ventricular dysfunction are
the most powerful (RR, > 2) predictors of 6-month mortality among
patients recovering from myocardial infarction after thrombolysis.
Qualitative variables reflecting residual myocardial ischemia do not appear
to be risk predictors. The lack of an independent adverse influence of
early post-myocardial infarction angina on 6-month survival represents a
major difference between this study and those of the prethrombolytic era.
ARTICLES
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GISSI Coordinating Center, Istituto di Ricerche Farmacologiche Mario Negri, Milano, Italy.
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