CLINICAL STUDY: MYOCARDIAL INFARCTION
Utility of current risk stratification tests for predicting major arrhythmic events after myocardial infarction
James J. Bailey, MD, MSc*,*,
Alan S. Berson, PHD ,
Harry Handelsman, DO and
Morrison Hodges, MD, FACC
* Center for Information Technology, National Institutes of Health, Bethesda, MarylandUSA
Bioengineering Scientific Research Group, National Heart, Lung, and Blood Institute, Bethesda, MarylandUSA
Center for Practice and Technology Assessment, Agency for Health Care Research and Quality, Bethesda, MarylandUSA
Minneapolis Heart Institute Foundation, Minneapolis, MinnesotaUSA
Manuscript received March 26, 2001;
revised manuscript received August 2, 2001,
accepted August 27, 2001.
* Reprint requests and correspondence: Dr. James J. Bailey, National Institutes of Health, Building 12A, Room 2007, MSC 5620, 9000 Rockville Pike, Bethesda, Maryland 20892-5620 USA
jjbailey{at}helix.nih.gov
OBJECTIVES
We surveyed the literature to estimate prediction values for five common tests for risk of major arrhythmic events (MAEs) after myocardial infarction. We then determined feasibility of a staged risk stratification using combinations of noninvasive tests, reserving an electrophysiologic study (EPS) as the final test.
BACKGROUND
Improved approaches are needed for identifying those patients at highest risk for subsequent MAE and candidates for implantable cardioverter-defibrillators.
METHODS
We located 44 reports for which values of MAE incidence and predictive accuracy could be inferred: signal-averaged electrocardiography; heart rate variability; severe ventricular arrhythmia on ambulatory electrocardiography; left ventricular ejection fraction; and EPS. A meta-analysis of reports used receiver-operating characteristic curves to estimate mean values for sensitivity and specificity for each test and 95% confidence limits. We then simulated a clinical situation in which risk was estimated by combining tests in three stages.
RESULTS
Test sensitivities ranged from 42.8% to 62.4%; specificities from 77.4% to 85.8%. A three-stage stratification yielded a low-risk group (80.0% with a two-year MAE risk of 2.9%), a high-risk group (11.8% with a 41.4% risk) and an unstratified group (8.2% with an 8.9% risk equivalent to a two-year incidence of 7.9%).
CONCLUSIONS
Sensitivities and specificities for the five tests were relatively similar. No one test was satisfactory alone for predicting risk. Combinations of tests in stages allowed us to stratify 91.8% of patients as either high-risk or low-risk. These data suggest that a large prospective study to develop a robust prediction model is feasible and desirable.
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Abbreviations and Acronyms
| | AECG | = ambulatory electrocardiography | | CI | = confidence interval | | EPS | = electrophysiologic study | | HRV | = heart rate variability | | ICD | = implantable cardioverter-defibrillator | | LVEF | = left ventricular ejection fraction | | MADIT | = Multicenter Automatic Defibrillator Implantation Trial | | MAE | = major arrhythmic event | | MI | = myocardial infarction | | NPA | = negative predictive accuracy | | PPA | = positive predictive accuracy | | ROC | = receiver-operating characteristic | | SAECG | = signal-averaged electrocardiogram | | SCD | = sudden cardiac death | | SVA | = serious ventricular arrhythmia | | VF | = ventricular fibrillation | | VT | = ventricular tachycardia |
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