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CLINICAL STUDY

Prognostic value of ST segment depression in acute coronary syndromes: insights from PARAGON-A applied to GUSTO-IIb¹

Padma Kaul, PhD^*, Yuling Fu, MD^*, Wei-Ching Chang, PhD^*, Robert A. Harrington, MD, Galen S. Wagner, MD, Shaun G. Goodman, MD, Christopher B. Granger, MD, David J. Moliterno, MD, Frans Van de Werf, MD^||, Robert M. Califf, MD, Eric J. Topol, MD, Paul W. Armstrong, MD^* for the PARAGON-A and GUSTO-IIb Investigators

^* University of Alberta, Edmonton, Alberta, Canada
Duke Clinical Research Institute, Durham, North Carolina, USA
St. Michael’s Hospital, Toronto, Ontario, Canada
Cleveland Clinic Foundation, Cleveland, Ohio, USA
^|| University Hospital Gasthuisberg, Leuven, Belgium

Manuscript received August 23, 2000; revised manuscript received March 21, 2001, accepted April 2, 2001.

Reprint requests and correspondence: Dr. Paul W. Armstrong, 2-51 Medical Sciences Building, University of Alberta, Edmonton, Alberta, Canada T6G 2H7
paul.armstrong{at}ualberta.ca

OBJECTIVES

Our objectives were to develop a risk-stratification model addressing the importance of the magnitude and distribution of ST segment depression in predicting long-term outcomes and to validate the model in an analogous patient population.

BACKGROUND

Although patients without ST segment elevation presenting with acute coronary syndromes represent an increasingly frequent population admitted to coronary care units, little attention has been paid to quantifying their ST segment abnormalities.

METHODS

ST segment depression was categorized into three groups: 1) no ST segment depression; 2) 1-mm ST segment depression in two contiguous leads; and 3) ST segment depression 2 mm in two contiguous leads. A logistic regression model was developed using Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network (PARAGON-A) data to assess the prognostic value of the extent and distribution of ST segment depression in predicting one-year mortality. The model was validated using the non-ST segment elevation population in Global Use of Strategies To Open occluded arteries in acute coronary syndromes (GUSTO-IIb).

RESULTS

ST segment depression was the strongest predictor of one-year mortality, accounting for 35% of the model’s predictive power. Patients with ST segment depression 2 mm were 6 times (odds ratio [OR] 5.73, 95% confidence interval [CI] 2.8 to 11.6) more likely to die within one year than patients with no ST segment depression. On validation, the model showed good discriminatory power (c-index = 0.75). Patients with ST segment depression 2 mm in more than one region were almost 10 times more likely to die within one year than patients with no ST segment depression.

CONCLUSIONS

These data provide new evidence supporting the powerful prognostic value of the baseline electrocardiogram and, in particular, the magnitude and distribution of ST segment depression in predicting unfavorable events.

Abbreviations and Acronyms   CABG = coronary artery bypass graft surgery   CI = confidence interval   ECG = electrocardiogram or electrocardiographic   GUSTO-IIb = Global Use of Strategies To Open occluded arteries in acute coronary syndromes   MI = myocardial infarction   OR = odds ratio   PARAGON-A = Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network

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