ST elevation myocardial infarction prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
The prognosis for patients with myocardial infarction varies greatly depending upon simple demographic variables like age, the presence of signs and symptoms of heart failure, the duration of symptoms, and comorbidities that are present. Several risk stratification tools have been developed to predict a patient's mortality. Most of these risk scores are based upon clinical data obtained at the time of admission rather than at the time of discharge.
Prognosis
Factors Associated with a Poor Prognosis in STEMI
While we as physicians often labor under the impression that we can dramatically change a patient's prognosis, it is noteworthy that 90% of the predictive information regarding 30 day mortality is contained in the following 5 baseline variables that can be modified to only a limited degree: [1]
- Advanced age
- Sinus tachycardia
- Reduced systolic blood pressure
- Heart failure or Killip class of two or greater
- Anterior myocardial infarction location
Sinus tachycardia, hypotension, Killip class, and anterior MI are all essentially markers of poor pump function on admission. These risk factors for 30 day mortality have been well validated in a multivariate analysis of 41,020 patients in the GUSTO-I trial. Advanced age was the most significant factor associated with higher 30-day mortality. The rate was only 1.1% in the youngest decile (< 45 years) and climbed to 20.5% in patients > 75 (adjusted chi 2 = 717, P < .0001). Other variables most closely associated with an increased risk of mortality were lower systolic blood pressure at randomization (chi 2 = 550, P < .0001), higher Killip class (chi 2 = 350, P < .0001), elevated heart rate (chi 2 = 275, P < .0001), and the presence of an anterior infarction (chi 2 = 143, P < .0001). When taken together, these five baseline characteristics contained 90% of the prognostic information. 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. When these variables were combined, a validated model was created which stratified patients according to their mortality risk and accurately estimated the likelihood of death.
Other Prognostic Variables not Identified in GUSTO I
Other risk factors include, serum creatinine concentration [2], and peripheral vascular disease.[3][4]
Left Ventricular Function as a Risk Stratifier
Assessment of left ventricular ejection fraction may increase the predictive power of some risk stratification models.[5] The prognostic importance of Q-waves is debated.[6] Prognosis is significantly worsened if a mechanical complication (papillary muscle rupture, myocardial free wall rupture, and so on) were to occur.
There is evidence that case fatality of myocardial infarction has been improving over the years in all ethnicities.[7]
STEMI Risk Scores
The Thrombolysis in Myocardial Infarction TIMI Risk Score [8] and TIMI Risk Index [9] are two prognostic indices that have been validated in clinical trials and epidemiologic studies to predict 30-day mortality among patients with STEMI.
The TIMI Risk Score incorporates eight clinical variables (age, systolic blood pressure [SBP], heart rate [HR], Killip class, anterior ST elevation or left bundle branch block on electrocardiogram, diabetes mellitus, history of hypertension or angina, low weight and time to treatment >4 hours) and assigns them a point value based on their odds ratio for mortality.
The TIMI Risk Score was developed and validated in clinical trials of fibrinolytic therapy, but it has also been reported to be prognostic in community-based real-world registries [10] as well as elderly patients [11].
The TIMI Risk Index incorporates age, HR and SBP (HR x [age/10] x 2/SBP), and has been validated in unselected patients [12], registries [13] and population-based cohorts [14]
Other risk tools such as the GRACE risk score have also been developed to risk stratify patients.
Interestingly, although tobacco abuse is a risk factor for CAD and STEMI, smoking is associated with a lower risk of mortality among patients who present with STEMI [15][16] This is due, at least in part, to the finding that smokers who present with STEMI are, on average, at least a decade younger than non-smokers. Smokers more often have involvement of the right coronary artery rather than the left anterior descending artery as well. Smokers paradoxically have better myocardial perfusion following reperfusion therapy than non smokers [17].
2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)[18]
Assessment of Left Ventricular Function (DO NOT EDIT)[18]
| Class I |
| "1. LV ejection fraction should be measured in all patients with STEMI. (Level of Evidence: C)" |
Sources
- 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction [18]
References
- ↑ Lee KL, Woodlief LH, Topol EJ, et al (March 1995). "Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Results from an international trial of 41,021 patients. GUSTO-I Investigators". Circulation 91 (6): 1659–68. PMID 7882472.
- ↑ Gibson CM, Pinto DS, Murphy SA, et al (November 2003). "Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality". J. Am. Coll. Cardiol. 42 (9): 1535–43. PMID 14607434.
- ↑ Fox KA, Dabbous OH, Goldberg RJ, et al (November 2006). "Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE)". BMJ 333 (7578): 1091. doi:10.1136/bmj.38985.646481.55. PMID 17032691.
- ↑ Weir RA, McMurray JJ, Velazquez EJ. (2006). "Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance.". Am J Cardiol 97 (10A): 13F-25F. PMID 16698331.
- ↑ Bosch X, Theroux P. (2005). "Left ventricular ejection fraction to predict early mortality in patients with non-ST-segment elevation acute coronary syndromes.". Am Heart J 150 (2): 215-20. PMID 16086920.
- ↑ Nicod P, Gilpin E, Dittrich H, Polikar R, Hjalmarson A, Blacky A, Henning H, Ross J (1989). "Short- and long-term clinical outcome after Q wave and non-Q wave myocardial infarction in a large patient population.". Circulation 79 (3): 528-36. PMID 2645061.
- ↑ Liew R, Sulfi S, Ranjadayalan K, Cooper J, Timmis AD. (2006). "Declining case fatality rates for acute myocardial infarction in South Asian and white patients in the past 15 years.". Heart 92 (8): 1030-4. PMID 16387823.
- ↑ Morrow DA, Antman EM, Charlesworth A, et al (October 2000). "TIMI risk score for ST-elevation myocardial infarction: A convenient, bedside, clinical score for risk assessment at presentation: An intravenous nPA for treatment of infarcting myocardium early II trial substudy". Circulation 102 (17): 2031–7. PMID 11044416.
- ↑ Morrow DA, Antman EM, Giugliano RP, et al (November 2001). "A simple risk index for rapid initial triage of patients with ST-elevation myocardial infarction: an InTIME II substudy". Lancet 358 (9293): 1571–5. doi:10.1016/S0140-6736(01)06649-1. PMID 11716882.
- ↑ Morrow DA, Antman EM, Parsons L, et al (September 2001). "Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3". JAMA 286 (11): 1356–9. PMID 11560541.
- ↑ Rathore SS, Weinfurt KP, Foody JM, Krumholz HM (September 2005). "Performance of the Thrombolysis in Myocardial Infarction (TIMI) ST-elevation myocardial infarction risk score in a national cohort of elderly patients". Am. Heart J. 150 (3): 402–10. doi:10.1016/j.ahj.2005.03.069. PMID 16169316.
- ↑ Ilkhanoff L, O'Donnell CJ, Camargo CA, O'Halloran TD, Giugliano RP, Lloyd-Jones DM (September 2005). "Usefulness of the TIMI Risk Index in predicting short- and long-term mortality in patients with acute coronary syndromes". Am. J. Cardiol. 96 (6): 773–7. doi:10.1016/j.amjcard.2005.04.059. PMID 16169358.
- ↑ Wiviott SD, Morrow DA, Frederick PD, et al (August 2004). "Performance of the thrombolysis in myocardial infarction risk index in the National Registry of Myocardial Infarction-3 and -4: a simple index that predicts mortality in ST-segment elevation myocardial infarction". J. Am. Coll. Cardiol. 44 (4): 783–9. doi:10.1016/j.jacc.2004.05.045. PMID 15312859.
- ↑ Bradshaw PJ, Ko DT, Newman AM, Donovan LR, Tu JV (January 2007). "Validation of the Thrombolysis In Myocardial Infarction (TIMI) risk index for predicting early mortality in a population-based cohort of STEMI and non-STEMI patients". Can J Cardiol 23 (1): 51–6. PMID 17245483.
- ↑ Gourlay SG, Rundle AC, Barron HV (February 2002). "Smoking and mortality following acute myocardial infarction: results from the National Registry of Myocardial Infarction 2 (NRMI 2)". Nicotine Tob. Res. 4 (1): 101–7. doi:10.1080/14622200110103205. PMID 11906686.
- ↑ Weisz G, Cox DA, Garcia E, et al (August 2005). "Impact of smoking status on outcomes of primary coronary intervention for acute myocardial infarction--the smoker's paradox revisited". Am. Heart J. 150 (2): 358–64. doi:10.1016/j.ahj.2004.01.032. PMID 16086943.
- ↑ Kirtane AJ, Martinezclark P, Rahman AM, et al (January 2005). "Association of smoking with improved myocardial perfusion and the angiographic characterization of myocardial tissue perfusion after fibrinolytic therapy for ST-segment elevation myocardial infarction". J. Am. Coll. Cardiol. 45 (2): 321–3. doi:10.1016/j.jacc.2004.10.018. PMID 15653037.
- ↑ 18.0 18.1 18.2 O'Gara PT, Kushner FG, Ascheim DD, et al. (December 2012). "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e3182742c84. PMID 23247303.
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