A simple electrocardiographic predictor of the outcome of patients with acute myocardial infarction treated with a thrombolytic agent. A Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)-Derived Analysis

OBJECTIVES. This analysis aimed to evaluate in a large patient cohort the relation between ST segment alterations after fibrinolytic therapy for acute myocardial infarction and 1) the combined end point of in-hospital mortality plus clinical congestive heart failure or extensive left ventricular damage, and 2) mortality 30 and 180 days after randomization. BACKGROUND. Angina relief, enzyme release acceleration and ST segment normalization are related to coronary artery reperfusion and prognosis. Electrocardiographic (ECG) evaluation before and after fibrinolytic drug administration has been used to predict short- and long-term clinical outcome in acute myocardial infarction. METHODS. Patients enrolled in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial underwent a standard ECG on admission and after 4 h of alteplase or streptokinase therapy; 7,426 recordings were suitable for ST segment analysis. A decrease > or = 50% in the sum of ST segment elevation in all ECG leads was adopted as the cutoff for predicting coronary artery patency. Recanalization was deemed to have occurred in 4,951 patients (group A) versus 2,475 patients without reperfusion (group B). RESULTS. Group A patients experienced a lower incidence of the combined end point than did group B patients (16.2% vs. 22.9%, respectively), as well as of all its components (death, clinical heart failure, ejection fraction < 35%, injured myocardial segment > 45%, QRS score > 10). Thirty- and 180-day mortality rates were lower in group A than group B (3.5% and 5.7% vs. 7.4% and 9.9%, respectively); relative risk (Cox) was 0.46 (95% confidence interval [CI] 0.37 to 0.57) for 30-day and 0.58 (95% CI 0.48 to 0.70) for 180-day mortality. Patients in group A had significantly less ventricular fibrillation and sustained ventricular tachycardia but more ischemic episodes (early recurrent angina plus myocardial infarction recurrence). CONCLUSIONS. A simple, inexpensive instrumental evaluation, unaffected by different epidemiologic and clinical characteristics of the population analyzed, can allow early assessment of the effectiveness of fibrinolytic treatment with respect to the main clinical outcomes.

This article has been cited by other articles:

				S. G. Goodman, V. Menon, C. P. Cannon, G. Steg, E. M. Ohman, and R. A. Harrington Acute ST-Segment Elevation Myocardial Infarction: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 708S - 775S. [Abstract] [Full Text] [PDF]

				M Toma, Y Fu, G Wagner, S G Goodman, C Granger, L Wallentin, F Van de Werf, and P Armstrong Risk stratification in ST-elevation myocardial infarction is enhanced by combining baseline ST deviation and subsequent ST-segment resolution Heart, March 1, 2008; 94(3): e6 - e6. [Abstract] [Full Text] [PDF]

				B. M. Scirica, D. A. Morrow, Z. Sadowski, M. Ruda, J. C. Nicolau, R. P. Giugliano, S. D. Wiviott, M. S. Sabatine, A. Shui, E. M. Antman, et al. A strategy of using enoxaparin as adjunctive antithrombin therapy reduces death and recurrent myocardial infarction in patients who achieve early ST-segment resolution after fibrinolytic therapy: the ExTRACT-TIMI 25 ECG study Eur. Heart J., September 1, 2007; 28(17): 2070 - 2076. [Abstract] [Full Text] [PDF]

				P. Silva-Orrego, P. Colombo, R. Bigi, D. Gregori, A. Delgado, P. Salvade, J. Oreglia, P. Orrico, A. de Biase, G. Piccalo, et al. Thrombus Aspiration Before Primary Angioplasty Improves Myocardial Reperfusion in Acute Myocardial Infarction: The DEAR-MI (Dethrombosis to Enhance Acute Reperfusion in Myocardial Infarction) Study J. Am. Coll. Cardiol., October 17, 2006; 48(8): 1552 - 1559. [Abstract] [Full Text] [PDF]

				B. M. Scirica, M. S. Sabatine, D. A. Morrow, C. M. Gibson, S. A. Murphy, S. D. Wiviott, R. P. Giugliano, C. H. McCabe, C. P. Cannon, and E. Braunwald The Role of Clopidogrel in Early and Sustained Arterial Patency After Fibrinolysis for ST-Segment Elevation Myocardial Infarction: The ECG CLARITY-TIMI 28 Study J. Am. Coll. Cardiol., July 4, 2006; 48(1): 37 - 42. [Abstract] [Full Text] [PDF]

				M. W. Krucoff, P. Johanson, R. Baeza, S. W. Crater, and M. Dellborg Clinical Utility of Serial and Continuous ST-Segment Recovery Assessment in Patients With Acute ST-Elevation Myocardial Infarction: Assessing the Dynamics of Epicardial and Myocardial Reperfusion Circulation, December 21, 2004; 110(25): e533 - e539. [Full Text] [PDF]

				M. G. McLaughlin, G. W. Stone, E. Aymong, G. Gardner, R. Mehran, A. J. Lansky, C. L. Grines, J. E. Tcheng, D. A. Cox, T. Stuckey, et al. Prognostic utility of comparative methods for assessment of ST-segment resolution after primary angioplasty for acute myocardial infarction: The controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC) trial J. Am. Coll. Cardiol., September 15, 2004; 44(6): 1215 - 1223. [Abstract] [Full Text] [PDF]

				P. Johanson, T. Jernberg, G. Gunnarsson, B. Lindahl, L. Wallentin, and M. Dellborg Prognostic value of ST-segment resolution--when and what to measure Eur. Heart J., February 2, 2003; 24(4): 337 - 345. [Abstract] [Full Text] [PDF]

				H. Mickley and S. Gill Is time the overriding factor in thrombolytic therapy? Eur. Heart J., March 1, 2002; 23(5): 347 - 349. [Full Text] [PDF]

				Y. Fu, S. Goodman, W.-C. Chang, F. Van de Werf, C. B. Granger, and P. W. Armstrong Time to Treatment Influences the Impact of ST-Segment Resolution on One-Year Prognosis: Insights From the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT-2) Trial Circulation, November 27, 2001; 104(22): 2653 - 2659. [Abstract] [Full Text] [PDF]

				J. A. de Lemos and E. Braunwald ST segment resolution as a tool for assessing the efficacy of reperfusion therapy J. Am. Coll. Cardiol., November 1, 2001; 38(5): 1283 - 1294. [Abstract] [Full Text] [PDF]

				A J O. Ophuis, F W Bar, F Vermeer, W Janssen, P A Doevendans, R J Haest, W R Dassen, and H J J Wellens Angiographic assessment of prospectively determined non-invasive reperfusion indices in acute myocardial infarction Heart, August 1, 2000; 84(2): 164 - 170. [Abstract] [Full Text] [PDF]

				J. Andrews, I. T. Straznicky, J. K. French, C. L. Green, A. C. P. Maas, M. Lund, M. W. Krucoff, and H. D. White ST-Segment Recovery Adds to the Assessment of TIMI 2 and 3 Flow in Predicting Infarct Wall Motion After Thrombolytic Therapy Circulation, May 9, 2000; 101(18): 2138 - 2143. [Abstract] [Full Text] [PDF]

				G. Liuzzo, L. M. Biasucci, J. R. Gallimore, G. Caligiuri, A. Buffon, A. G. Rebuzzi, M. B. Pepys, and A. Maseri Enhanced inflammatory response in patients with preinfarction unstable angina J. Am. Coll. Cardiol., November 15, 1999; 34(6): 1696 - 1703. [Abstract] [Full Text] [PDF]

				I F Purcell, N Newall, and M Farrer Change in ST segment elevation 60 minutes after thrombolytic initiation predicts clinical outcome as accurately as later electrocardiographic changes Heart, November 1, 1997; 78(5): 465 - 471. [Abstract] [Full Text] [PDF]

				T. Moccetti, R. Malacrida, E. Pasotti, F. Sessa, M. Genoni, S. Barlera, F. Turazza, and A. P. Maggioni Epidemiologic Variables and Outcome of 1972 Young Patients With Acute Myocardial Infarction: Data From the GISSI-2 Database Arch Intern Med, April 28, 1997; 157(8): 865 - 869. [Abstract] [PDF]