Aims: To demonstrate the feasibility and clinical utility of developing dynamic risk assessment models for ST- segment elevation myocardial infarction(STEMI) patients. Methods and results: In 6066 STEMI patients enrol...Aims: To demonstrate the feasibility and clinical utility of developing dynamic risk assessment models for ST- segment elevation myocardial infarction(STEMI) patients. Methods and results: In 6066 STEMI patients enrolled in the Assessment of the Safety and Efficacy of a New Thrombolytic- 3(ASSENT- 3) trial with complete electrocardiographic data, we assessed the probability of 30- day mortality over the following forecasting periods beginning at day 0(baseline), 3 h, day 2, and day 5 using multiple- logistic regression. These models were validated and simplified in independent samples of 1622 similar fibrinolytic- treated p atients from the ASSENT- 3 PLUS trial and in 814 STEMI patients undergoing primary percutaneous coronary intervention in the COMplement inhibition in Myocardial infarction treated with Angioplasty(COMMA)trial. The discriminatory power of these predictive models, from baseline to day 5, was excellent(c- statistics 0.80 to 0.87); and their predictive ability was supported by strong gradients in mortality outcomes as the risk score increased. Dynamic modelling also provided information on the change in prognosis over time which may be used to advise more appropriate therapeutic decisions, e.g. the identification of high- risk patients for possible co- interventions. Conclusion: Dynamic modelling for STEMI patients enhances the risk assessment and stratification and should provide valuable ongoing guidance for their management.展开更多
Objectives: To examine the interaction between ST segment depression on the baseline ECG and subsequent in-hospital revascularisation on six month mortality among patients with non-ST elevation acute coronary syndrome...Objectives: To examine the interaction between ST segment depression on the baseline ECG and subsequent in-hospital revascularisation on six month mortality among patients with non-ST elevation acute coronary syndromes. To examine whether ST segment depression influenced clinical decision making and whether there was international variation in the use of cardiac procedures across ST segment depression categories. Methods: 11 453 patients enrolled in GUSTO-IIB(global use of strategies to open occluded coronary arteries), PARAGON(platelet IIb/IIIa antagonism for the reduction of acute coronary syndrome events in a global organisation network)-A, and PARAGON-B were studied. Patients were categorised as having no ST segment depression, 1 mm ST segment depression in two contiguous leads, and ST segment depression ≥2 mm in two contiguous leads. International practice across four geographic regions was examined: USA, Canada, Europe, and Australia/NewZealand. Results: Revascularisation appeared to have no impact on survival among patients with no ST segment depression; however, revascularisation was associated with a significant survival benefit among patients with ST segment depression ≥1 mm. There was an inverse relation between the extent of ST segment depression and the use of angiography as well as angioplasty(p< 0.01). However, patients with ST segment depression≥2mm were more likely to undergo bypass surgery. The only significant trend of increasing use of revascularisation procedures with increasing ST segment depression was observed in the USA. Conclusions: International practice patterns in procedure use appear to be insensitive to the extent of ST segment depression. Major opportunities for more efficient delivery of care exist in all regions.展开更多
文摘Aims: To demonstrate the feasibility and clinical utility of developing dynamic risk assessment models for ST- segment elevation myocardial infarction(STEMI) patients. Methods and results: In 6066 STEMI patients enrolled in the Assessment of the Safety and Efficacy of a New Thrombolytic- 3(ASSENT- 3) trial with complete electrocardiographic data, we assessed the probability of 30- day mortality over the following forecasting periods beginning at day 0(baseline), 3 h, day 2, and day 5 using multiple- logistic regression. These models were validated and simplified in independent samples of 1622 similar fibrinolytic- treated p atients from the ASSENT- 3 PLUS trial and in 814 STEMI patients undergoing primary percutaneous coronary intervention in the COMplement inhibition in Myocardial infarction treated with Angioplasty(COMMA)trial. The discriminatory power of these predictive models, from baseline to day 5, was excellent(c- statistics 0.80 to 0.87); and their predictive ability was supported by strong gradients in mortality outcomes as the risk score increased. Dynamic modelling also provided information on the change in prognosis over time which may be used to advise more appropriate therapeutic decisions, e.g. the identification of high- risk patients for possible co- interventions. Conclusion: Dynamic modelling for STEMI patients enhances the risk assessment and stratification and should provide valuable ongoing guidance for their management.
文摘Objectives: To examine the interaction between ST segment depression on the baseline ECG and subsequent in-hospital revascularisation on six month mortality among patients with non-ST elevation acute coronary syndromes. To examine whether ST segment depression influenced clinical decision making and whether there was international variation in the use of cardiac procedures across ST segment depression categories. Methods: 11 453 patients enrolled in GUSTO-IIB(global use of strategies to open occluded coronary arteries), PARAGON(platelet IIb/IIIa antagonism for the reduction of acute coronary syndrome events in a global organisation network)-A, and PARAGON-B were studied. Patients were categorised as having no ST segment depression, 1 mm ST segment depression in two contiguous leads, and ST segment depression ≥2 mm in two contiguous leads. International practice across four geographic regions was examined: USA, Canada, Europe, and Australia/NewZealand. Results: Revascularisation appeared to have no impact on survival among patients with no ST segment depression; however, revascularisation was associated with a significant survival benefit among patients with ST segment depression ≥1 mm. There was an inverse relation between the extent of ST segment depression and the use of angiography as well as angioplasty(p< 0.01). However, patients with ST segment depression≥2mm were more likely to undergo bypass surgery. The only significant trend of increasing use of revascularisation procedures with increasing ST segment depression was observed in the USA. Conclusions: International practice patterns in procedure use appear to be insensitive to the extent of ST segment depression. Major opportunities for more efficient delivery of care exist in all regions.
