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{{Infobox_Disease |
__NOTOC__
  Name          = Myocardial infarction|
{{ST elevation myocardial infarction}}
  Image          = |
{{CMG}}; '''Associate Editors-In-Chief:''' {{CZ}}
  Caption        = |
  DiseasesDB    = 8664 |
  ICD10          = {{ICD10|I|21||i|20}}-{{ICD10|I|22||i|20}} |
  ICD9          = {{ICD9|410}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = 000195 |
  eMedicineSubj  = med |
  eMedicineTopic = 1567 |
  eMedicine_mult = {{eMedicine2|emerg|327}} {{eMedicine2|ped|2520}} |
  MeshID        = |
}}
{{SI}}
{{WikiDoc Cardiology Network Infobox}}
{{CMG}}


'''Associate Editors-In-Chief:''' {{CZ}}
==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.
{{EJ}}


==Prognosis==
==Prognosis==
 
===Factors Associated with a Poor Prognosis in STEMI===
The prognosis for patients with myocardial infarction varies greatly, depending on the patient, the condition itself and the given treatment. Using simple variables which are immediately available in the [[emergency room]], patients with a higher risk of adverse outcome can be identified. For example, one study found that 0.4% of patients with a low risk profile had died after 90 days, whereas the [[mortality rate]] in high risk patients was 21.1%.<ref name="PEPA">Lopez de Sa E, Lopez-Sendon J, Anguera I, Bethencourt A, Bosch X; Proyecto de Estudio del Pronostico de la Angina (PEPA) Investigators. "Prognostic value of clinical variables at presentation in patients with non-ST-segment elevation acute coronary syndromes: results of the Proyecto de Estudio del Pronostico de la Angina (PEPA)." ''Medicine (Baltimore)'' 2002; '''81'''(6): 434-42. PMID 12441900</ref>
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: <ref name="pmid7882472">{{cite journal |author=Lee KL, Woodlief LH, Topol EJ, ''et al'' |title=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 |journal=Circulation |volume=91 |issue=6 |pages=1659–68 |year=1995 |month=March |pmid=7882472 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7882472}}</ref>
 
Although studies differ in the identified variables, some of the more reproducible risk factors for higher mortality include:
#Advanced age
#Advanced age
#[[Sinus tachycardia]]
#[[Sinus tachycardia]]
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#Anterior myocardial infarction location
#Anterior myocardial infarction location


Other risk factors include [[diabetes mellitus|diabetes]], [[Blood plasma|serum]] [[creatinine]] concentration, and [[Peripheral artery occlusive disease|peripheral vascular disease]].<ref name="PEPA"/><ref name="GRACE">Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, Avezum A, Goodman SG, Flather MD, Anderson FA Jr, Granger CB. "Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE)." ''BMJ'' 2006; '''333'''(7578):1091. PMID 17032691</ref><ref name="Weir-2006">{{cite journal | author=Weir RA, McMurray JJ, Velazquez EJ. | title=Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance. | journal=Am J Cardiol | year=2006 | volume=97 | issue=10A | pages=13F-25F | id=PMID 16698331}}</ref>
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.


Assesment of [[left ventricle|left ventricular]] [[ejection fraction]] may increase the predictive power of some risk stratification models.<ref name="Bosch-2005">{{cite journal | author=Bosch X, Theroux P. | title=Left ventricular ejection fraction to predict early mortality in patients with non-ST-segment elevation acute coronary syndromes. | journal=Am Heart J | year=2005 | volume=150 | issue=2 | pages=215-20 | id=PMID 16086920}}</ref>  The prognostic importance of Q-waves is debated.<ref>{{cite journal | author = Nicod P, Gilpin E, Dittrich H, Polikar R, Hjalmarson A, Blacky A, Henning H, Ross J | title = Short- and long-term clinical outcome after Q wave and non-Q wave myocardial infarction in a large patient population. | journal = Circulation | volume = 79 | issue = 3 | pages = 528-36 | year = 1989 | id = PMID 2645061}}</ref> Prognosis is significantly worsened if a mechanical complication ([[papillary muscle]] rupture, myocardial free wall rupture, and so on) were to occur.
===Other Prognostic Variables not Identified in GUSTO I===
Other risk factors include, [[serum creatinine]] concentration <ref name="pmid14607434">{{cite journal |author=Gibson CM, Pinto DS, Murphy SA, ''et al'' |title=Association of creatinine and creatinine clearance on presentation in acute myocardial infarction with subsequent mortality |journal=J. Am. Coll. Cardiol. |volume=42 |issue=9 |pages=1535–43 |year=2003 |month=November |pmid=14607434 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109703010672}}</ref>, and [[Peripheral artery occlusive disease|peripheral vascular disease]].<ref name="pmid17032691">{{cite journal |author=Fox KA, Dabbous OH, Goldberg RJ, ''et al'' |title=Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE) |journal=BMJ |volume=333 |issue=7578 |pages=1091 |year=2006 |month=November |pmid=17032691 |pmc=1661748 |doi=10.1136/bmj.38985.646481.55 |url=}}</ref><ref name="Weir-2006">{{cite journal | author=Weir RA, McMurray JJ, Velazquez EJ. | title=Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance. | journal=Am J Cardiol | year=2006 | volume=97 | issue=10A | pages=13F-25F | id=PMID 16698331}}</ref>
 
===Left Ventricular Function as a Risk Stratifier===
Assessment of left ventricular [[ejection fraction]] may increase the predictive power of some risk stratification models.<ref name="Bosch-2005">{{cite journal | author=Bosch X, Theroux P. | title=Left ventricular ejection fraction to predict early mortality in patients with non-ST-segment elevation acute coronary syndromes. | journal=Am Heart J | year=2005 | volume=150 | issue=2 | pages=215-20 | id=PMID 16086920}}</ref>  The prognostic importance of Q-waves is debated.<ref>{{cite journal | author = Nicod P, Gilpin E, Dittrich H, Polikar R, Hjalmarson A, Blacky A, Henning H, Ross J | title = Short- and long-term clinical outcome after Q wave and non-Q wave myocardial infarction in a large patient population. | journal = Circulation | volume = 79 | issue = 3 | pages = 528-36 | year = 1989 | id = PMID 2645061}}</ref> Prognosis is significantly worsened if a mechanical complication ([[papillary muscle rupture]], [[myocardial 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.<ref name="Liew-2006">{{cite journal | author=Liew R, Sulfi S, Ranjadayalan K, Cooper J, Timmis AD. | title=Declining case fatality rates for acute myocardial infarction in South Asian and white patients in the past 15 years. | journal=Heart | year=2006 | volume=92 | issue=8 | pages=1030-4 | id=PMID 16387823}}</ref>
There is evidence that case fatality of myocardial infarction has been improving over the years in all ethnicities.<ref name="Liew-2006">{{cite journal | author=Liew R, Sulfi S, Ranjadayalan K, Cooper J, Timmis AD. | title=Declining case fatality rates for acute myocardial infarction in South Asian and white patients in the past 15 years. | journal=Heart | year=2006 | volume=92 | issue=8 | pages=1030-4 | id=PMID 16387823}}</ref>


The Thrombolysis in Myocardial Infarction TIMI Risk Score <ref>Morrow DA, Antman EM, Charlesworth A, et al. 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 2000; 102:2031-7. </ref> and TIMI Risk Index <ref>Morrow DA, Antman EM, Giugliano RP, et al. A simple risk index for rapid initial triage of patients with ST elevation myocardial infarction: an InTIME II substudy. Lancet 2001; 358:1571-5. </ref> are two prognostic indices that have been validated in clinical trials and epidemiologic studies to predict 30-day mortality among patients with [[STEMI]].  
===STEMI Risk Scores===
The Thrombolysis in Myocardial Infarction TIMI Risk Score <ref name="pmid11044416">{{cite journal |author=Morrow DA, Antman EM, Charlesworth A, ''et al'' |title=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 |journal=Circulation |volume=102 |issue=17 |pages=2031–7 |year=2000 |month=October |pmid=11044416 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=11044416}}</ref> and TIMI Risk Index <ref name="pmid11716882">{{cite journal |author=Morrow DA, Antman EM, Giugliano RP, ''et al'' |title=A simple risk index for rapid initial triage of patients with ST-elevation myocardial infarction: an InTIME II substudy |journal=Lancet |volume=358 |issue=9293 |pages=1571–5 |year=2001 |month=November |pmid=11716882 |doi=10.1016/S0140-6736(01)06649-1 |url=}}</ref> 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 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 <ref>Morrow DA, Antman EM, Parsons L, et al. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. Jama 2001; 286:1356-9. </ref> as well as elderly patients <ref>Rathore SS, Weinfurt KP, Foody JM, Krumholz HM. Performance of the Thrombolysis in Myocardial Infarction (TIMI) ST-elevation myocardial infarction risk score in a national cohort of elderly patients. Am Heart J 2005; 150: 402-10. </ref>.  
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 <ref name="pmid11560541">{{cite journal |author=Morrow DA, Antman EM, Parsons L, ''et al'' |title=Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3 |journal=JAMA |volume=286 |issue=11 |pages=1356–9 |year=2001 |month=September |pmid=11560541 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=11560541}}</ref> as well as elderly patients <ref name="pmid16169316">{{cite journal |author=Rathore SS, Weinfurt KP, Foody JM, Krumholz HM |title=Performance of the Thrombolysis in Myocardial Infarction (TIMI) ST-elevation myocardial infarction risk score in a national cohort of elderly patients |journal=Am. Heart J. |volume=150 |issue=3 |pages=402–10 |year=2005 |month=September |pmid=16169316 |doi=10.1016/j.ahj.2005.03.069 |url=}}</ref>.  


The TIMI Risk Index incorporates age, HR and SBP (HR x [age/10] x 2/SBP), and has been validated in unselected patients <ref>Ilkhanoff L, O'Donnell CJ, Camargo CA, O'Halloran TD, Giugliano RP, Lloyd-Jones DM. Usefulness of the TIMI Risk Index in predicting short- and long-term mortality in patients with acute coronary syndromes. Am J Cardiol 2005; 96:773-7 </ref>, registries <ref>Wiviott SD, Morrow DA, Frederick PD, et al. 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 2004; 44:783-9. </ref> and population-based cohorts <ref>Bradshaw PJ, Ko DT, Newman AM, Donovan LR, Tu JV. 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 2007; 23: 51-6 </ref>
The TIMI Risk Index incorporates age, HR and SBP (HR x [age/10] x 2/SBP), and has been validated in unselected patients <ref name="pmid16169358">{{cite journal |author=Ilkhanoff L, O'Donnell CJ, Camargo CA, O'Halloran TD, Giugliano RP, Lloyd-Jones DM |title=Usefulness of the TIMI Risk Index in predicting short- and long-term mortality in patients with acute coronary syndromes |journal=Am. J. Cardiol. |volume=96 |issue=6 |pages=773–7 |year=2005 |month=September |pmid=16169358 |doi=10.1016/j.amjcard.2005.04.059 |url=}}</ref>, registries <ref name="pmid15312859">{{cite journal |author=Wiviott SD, Morrow DA, Frederick PD, ''et al'' |title=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 |journal=J. Am. Coll. Cardiol. |volume=44 |issue=4 |pages=783–9 |year=2004 |month=August |pmid=15312859 |doi=10.1016/j.jacc.2004.05.045 |url=}}</ref> and population-based cohorts <ref name="pmid17245483">{{cite journal |author=Bradshaw PJ, Ko DT, Newman AM, Donovan LR, Tu JV |title=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 |journal=Can J Cardiol |volume=23 |issue=1 |pages=51–6 |year=2007 |month=January |pmid=17245483 |doi= |url=}}</ref>


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]] <ref>Gourlay SG, Rundle AC, Barron HV. Smoking and mortality following acute myocardial infarction: results from the National Registry of Myocardial Infarction 2 (NRMI 2). Nicotine Tob Res 2002; 4: 101-7. </ref> <ref>Weisz G, Cox DA, Garcia E, et al. Impact of smoking status on outcomes of primary coronary intervention for acute myocardial infarction--the smoker's paradox revisited. Am Heart J 2005; 150: 358-64 </ref> 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 (Kirtane et al).
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]] <ref name="pmid11906686">{{cite journal |author=Gourlay SG, Rundle AC, Barron HV |title=Smoking and mortality following acute myocardial infarction: results from the National Registry of Myocardial Infarction 2 (NRMI 2) |journal=Nicotine Tob. Res. |volume=4 |issue=1 |pages=101–7 |year=2002 |month=February |pmid=11906686 |doi=10.1080/14622200110103205 |url=}}</ref><ref name="pmid16086943">{{cite journal |author=Weisz G, Cox DA, Garcia E, ''et al'' |title=Impact of smoking status on outcomes of primary coronary intervention for acute myocardial infarction--the smoker's paradox revisited |journal=Am. Heart J. |volume=150 |issue=2 |pages=358–64 |year=2005 |month=August |pmid=16086943 |doi=10.1016/j.ahj.2004.01.032 |url=}}</ref> 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 <ref name="pmid15653037">{{cite journal |author=Kirtane AJ, Martinezclark P, Rahman AM, ''et al'' |title=Association of smoking with improved myocardial perfusion and the angiographic characterization of myocardial tissue perfusion after fibrinolytic therapy for ST-segment elevation myocardial infarction |journal=J. Am. Coll. Cardiol. |volume=45 |issue=2 |pages=321–3 |year=2005 |month=January |pmid=15653037 |doi=10.1016/j.jacc.2004.10.018 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(04)02035-2}}</ref>.
 
==2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction (DO NOT EDIT)<ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=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 |journal=Circulation |volume= |issue= |pages= |year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>==
 
===Assessment of Left Ventricular Function (DO NOT EDIT)<ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=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 |journal=Circulation |volume= |issue= |pages= |year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[LV]] [[ejection fraction]] should be measured in all patients with [[STEMI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
==Sources==
* 2013 Revised ACCF/AHA Guidelines for the Management of ST-Elevation Myocardial Infarction <ref name="pmid23247303">{{cite journal |author=O'Gara PT, Kushner FG, Ascheim DD, ''et al.'' |title=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 |journal=Circulation |volume= |issue= |pages= |year=2012 |month=December |pmid=23247303 |doi=10.1161/CIR.0b013e3182742c84|url=}}</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


==External links==
[[Category:Disease]]
* [http://www.themdtv.org The MD TV: Comments on Hot Topics, State of the Art Presentations in Cardiovascular Medicine, Expert Reviews on Cardiovascular Research]
* [http://www.clinicaltrialresults.org Clinical Trial Results: An up to dated resource of Cardiovascular Research]
* [http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pub Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack] - based on information of the [[Framingham Heart Study]], from the United States [[National Heart, Lung and Blood Institute]]
* [http://www.nlm.nih.gov/medlineplus/heartattack.html Heart Attack] - overview of resources from [[MedlinePlus]].
* [http://ww2.heartandstroke.ca/Page.asp?PageID=1975&ArticleID=5288 Heart Attack Warning Signals] from the Heart and Stroke Foundation of Canada
* [http://www.regionalpci-stemi.org/index.html Regional PCI for STEMI Resource Center] - Evidence based online resource center for the development of regional PCI networks for acute STEMI
* [http://www.stemisystems.org/ STEMI Systems] - Articles, profiles, and reviews of the latest publications involved in STEMI care. Quarterly newsletter.
* [http://d2b.acc.org/ American College of Cardiology (ACC) Door to Balloon (D2B) Initiative.]
* [http://www.americanheart.org/heartattack American Heart Association's Heart Attack web site] - Information and resources for preventing, recognizing and treating heart attack.
 
{{STEMI}}
 
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Latest revision as of 14:31, 31 January 2013

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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]

  1. Advanced age
  2. Sinus tachycardia
  3. Reduced systolic blood pressure
  4. Heart failure or Killip class of two or greater
  5. 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

  1. ↑ Lee KL, Woodlief LH, Topol EJ; et al. (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. Unknown parameter |month= ignored (help)
  2. ↑ Gibson CM, Pinto DS, Murphy SA; et al. (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. Unknown parameter |month= ignored (help)
  3. ↑ Fox KA, Dabbous OH, Goldberg RJ; et al. (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. PMC 1661748. PMID 17032691. Unknown parameter |month= ignored (help)
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ Morrow DA, Antman EM, Charlesworth A; et al. (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. Unknown parameter |month= ignored (help)
  9. ↑ Morrow DA, Antman EM, Giugliano RP; et al. (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. Unknown parameter |month= ignored (help)
  10. ↑ Morrow DA, Antman EM, Parsons L; et al. (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. Unknown parameter |month= ignored (help)
  11. ↑ Rathore SS, Weinfurt KP, Foody JM, Krumholz HM (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. Unknown parameter |month= ignored (help)
  12. ↑ Ilkhanoff L, O'Donnell CJ, Camargo CA, O'Halloran TD, Giugliano RP, Lloyd-Jones DM (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. Unknown parameter |month= ignored (help)
  13. ↑ Wiviott SD, Morrow DA, Frederick PD; et al. (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. Unknown parameter |month= ignored (help)
  14. ↑ Bradshaw PJ, Ko DT, Newman AM, Donovan LR, Tu JV (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. Unknown parameter |month= ignored (help)
  15. ↑ Gourlay SG, Rundle AC, Barron HV (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. Unknown parameter |month= ignored (help)
  16. ↑ Weisz G, Cox DA, Garcia E; et al. (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. Unknown parameter |month= ignored (help)
  17. ↑ Kirtane AJ, Martinezclark P, Rahman AM; et al. (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. Unknown parameter |month= ignored (help)
  18. ↑ 18.0 18.1 18.2 O'Gara PT, Kushner FG, Ascheim DD; et al. (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. Unknown parameter |month= ignored (help)


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