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CLINICAL STUDIES

Long-term (three-year) prognosis of patients treated with reperfusion or conservatively after acute myocardial infarction

Shmuel Gottlieb, MD^* , Valentina Boyko, MSc^*, David Harpaz, MD^*, Hanoch Hod, MD, FACC^*, Miriam Cohen, BSc^*, Lori Mandelzweig, MPH^*, Zahi Khoury, MD, Shlomo Stern, MD, FACC, Solomon Behar, MD^* for the Israeli Thrombolytic Survey Group

^* Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel
Heiden Department of Cardiology, Bikur Cholim Hospital, Jerusalem, Israel. A complete list of the study participants appears in J Am Coll Cardiol 1996;28:1506–13

Manuscript received February 11, 1999; accepted March 19, 1999.

Reprint requests and correspondence: Dr. Shmuel Gottlieb, Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, 52621 Israel
SGOTT{at}MD2.HUJI.AC.IL

OBJECTIVES

This survey sought to assess the frequency of the use of thrombolytic therapy, invasive coronary procedures (ICP) (angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting [CABG]), variables associated with their use, and their impact on early (30-day) and long-term (3-year) mortality after acute myocardial infarction (AMI).

BACKGROUND

Few data are available regarding the implementation in daily practice of the results of clinical trials of treatments for AMI and their impact on early and long-term prognosis in unselected patients after AMI.

METHODS

A prospective community-based national survey was conducted during January–February 1994 in all 25 coronary care units operating in Israel.

RESULTS

Among 999 consecutive patients with an AMI (72% men; mean age 63 ± 12 years) acute reperfusion therapy (ART) was used in 455 patients (46%; thrombolysis in 435 patients [44%] and primary angioplasty in 20 [2%]). Its use was independently associated with anterior AMI location and hospitals with on-site angioplasty facilities, whereas advancing age, prior myocardial infarction (MI) and prior angioplasty or CABG were independently associated with its lower use. The three-year mortality of patients treated with ART was lower than in counterpart patients (22.0% vs. 31.4%, p = 0.0008), mainly as the result of 30-day to 3-year outcome (12.4% vs. 21.1%; hazard ratio = 0.73, 95% confidence interval [CI] 0.52 to 1.03). Independent predictors of long-term mortality were: age, heart failure on admission or during the hospitalization, ventricular tachycardia or fibrillation and diabetes. The outcome of patients not treated with ART differed according to the reason for the exclusion, where patients with contraindications experienced the highest three-year (50%) mortality rate. After ART, coronary angiography, angioplasty and CABG were performed in-hospital in 28%, 12% and 5% of patients, respectively. Their use was independently associated with recurrent infarction or ischemia, on-site catheterization or CABG facilities, non–Q-wave AMI and anterior infarct location. In the entire study population, and in patients with a non–Q-wave AMI, performance of ICP was associated with lower 30-day mortality (odds ratio [OR] = 0.53, 95% CI 0.25 to 0.98, and OR = 0.21, 0.03 to 0.84, respectively), but not thereafter.

CONCLUSIONS

This survey demonstrates the extent of implementation in daily practice of ART and ICP and their impact on early and long-term prognosis in an unselected population after AMI.

Abbreviations and Acronyms   AMI = acute myocardial infarction   ART = acute reperfusion therapy   CABG = coronary artery bypass grafting   CCU = coronary care unit   CI = confidence interval   ECG = electrocardiogram   HR = hazard ratio   ICP = invasive coronary procedures   MI = myocardial infarction   NQWMI = non–Q-wave myocardial infarction   OR = odds ratio   TIMI = Thrombolysis in Myocardial Infarction   tPA = tissue-type plasminogen activator

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