(Circulation. 1995;91:1659-1668.)
© 1995 American Heart Association, Inc.
Articles |
Predictors of 30-Day Mortality in the Era of Reperfusion for Acute Myocardial Infarction
Results From an International Trial of 41 021 Patients
From the Departments of Community and Family Medicine (Biometry) (K.L.L.) and Medicine (Cardiology) (L.H.W., R.M.C.), Duke University Medical Center, Durham, NC; the Department of Cardiology, Cleveland (Ohio) Clinic Foundation (E.J.T.); the Department of Medicine (Cardiology), University of Washington, Seattle (W.D.W.); Hospital Clinic I, Barcelona, Spain (A.B.); Clinique Universitaire St Luc, Bruxelles, Belgium (J.C.); the Thoraxcenter, Erasmus Universiteit, Rotterdam, The Netherlands (M.S.); the Department of Cardiovascular Medicine, Flinders Medical Center, Bedford Park, SA, Australia (P.A.); and the Department of Cardiology, University of Leuven (Belgium) (F. Van de W.).
Correspondence to Kerry L. Lee, PhD, Associate Professor, Biometry Division, Community and Family Medicine, Box 3363, Duke University Medical Center, Durham, NC 27710.
Background Despite remarkable advances in the treatment of acute myocardial infarction, substantial early patient mortality remains. Appropriate choices among alternative therapies and the use of clinical resources depend on an estimate of the patient's risk. Individual patients reflect a combination of clinical features that influence prognosis, and these factors must be appropriately weighted to produce an accurate assessment of risk. Prior studies to define prognosis either were performed before widespread use of thrombolysis or were limited in sample size or spectrum of data. Using the large population of the GUSTO-I trial, we performed a comprehensive analysis of relations between baseline clinical data and 30-day mortality and developed a multivariable statistical model for risk assessment in candidates for thrombolytic therapy.
Methods and Results For the 41 021 patients enrolled in GUSTO-I,
a randomized trial of four thrombolytic strategies, relations between
clinical descriptors routinely collected at initial presentation,
and death within 30 days (which occurred in 7% of the population) were
examined with both univariable and multivariable analyses. Variables
studied included demographics, history and risk factors, presenting
characteristics, and treatment assignment. Risk modeling was performed
with logistic multiple regression and validated with bootstrapping
techniques. Multivariable analysis identified age as the most
significant factor influencing 30-day mortality, with rates of 1.1% in
the youngest decile (<45 years) and 20.5% in patients >75 (adjusted
2=717, P<.0001). Other factors most
significantly associated with increased mortality were lower systolic
blood pressure (2=550, P<.0001),
higher Killip class (2=350, P<.0001),
elevated heart rate (2=275, P<.0001),
and anterior infarction (2=143,
P<.0001). Together, these five characteristics contained
90% of the prognostic information in the baseline clinical data. Other
significant though less important factors included previous myocardial
infarction, height, time to treatment, diabetes, weight, smoking
status, type of thrombolytic, previous bypass surgery, hypertension,
and prior cerebrovascular disease. Combining prognostic variables
through logistic regression, we produced a validated model that
stratified patient risk and accurately estimated the likelihood of
death.
Conclusions The clinical determinants of mortality in patients treated with thrombolytic therapy within 6 hours of symptom onset are multifactorial and the relations complex. Although a few variables contain most of the prognostic information, many others contribute additional independent prognostic information. Through consideration of multiple characteristics, including age, medical history, physiological significance of the infarction, and medical treatment, the prognosis of an individual patient can be accurately estimated.
Key Words: myocardial infarction • prognosis • risk factors • thrombolysis
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J. E. Madias The Impact of Systemic BP on Coronary Blood Flow and Infarct Size During Reperfusion Therapy for Acute Myocardial Infarction: Refinements Beyond the "Plumbing" Chest, April 1, 2004; 125(4): 1179 - 1181. [Full Text] [PDF]
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D. S. Lee, P. C. Austin, J. L. Rouleau, P. P. Liu, D. Naimark, and J. V. Tu Predicting Mortality Among Patients Hospitalized for Heart Failure: Derivation and Validation of a Clinical Model JAMA, November 19, 2003; 290(19): 2581 - 2587. [Abstract] [Full Text] [PDF]
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M. C. Tjandrawidjaja, Y. Fu, S. G. Goodman, F. Van de Werf, C. B. Granger, P. W. Armstrong, and for the ASSENT-2 Investigators The impact of gender on the treatment and outcomes of patients with early reinfarction after fibrinolysis: insights from ASSENT-2{star} Eur. Heart J., June 1, 2003; 24(11): 1024 - 1034. [Abstract] [Full Text] [PDF]
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J. P.S. Henriques, F. Zijlstra, M.-J. de Boer, A. W.J. van't Hof, A.T. M. Gosselink, J.-H. E. Dambrink, H. Suryapranata, and J. C.A. Hoorntje The prognostic importance of heart failure and age in patients treated with primary angioplasty Eur J Heart Fail, June 1, 2003; 5(3): 291 - 294. [Abstract] [Full Text] [PDF]
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L.K Newby, M.V Bhapkar, H.D White, E.J Topol, F.C Dougherty, R.A Harrington, M.C Smith, L.F Asarch, R.M Califf, and for the SYMPHONY and 2nd SYMPHONY Investigators Predictors of 90-day outcome in patients stabilized after acute coronary syndromes Eur. Heart J., January 2, 2003; 24(2): 172 - 181. [Abstract] [Full Text] [PDF]
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J. Al Suwaidi, D. N. Reddan, K. Williams, K. S. Pieper, R. A. Harrington, R. M. Califf, C. B. Granger, E. M. Ohman, D. R. Holmes Jr, and for the GUSTO-IIb, GUSTO-III, PURSUIT, and PARAGON Prognostic Implications of Abnormalities in Renal Function in Patients With Acute Coronary Syndromes Circulation, August 20, 2002; 106(8): 974 - 980. [Abstract] [Full Text] [PDF]
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