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CLINICAL RESEARCH: CLINICAL TRIAL

Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the thrombolysis in myocardial infarction trials

^* Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

Manuscript received October 15, 2002; revised manuscript received December 5, 2002, accepted December 18, 2002.

^* Reprint requests and correspondence: Dr. C. Michael Gibson, TIMI Study Group, 350 Longwood Avenue, 1st Floor, Boston, Massachusetts 02115, USA.
mgibson{at}perfuse.org

OBJECTIVES: We hypothesized that early recurrent myocardial infarction (MI) following fibrinolytic administration would be assessed with higher mortality at both 30 days and 2 years.

BACKGROUND: Although early recurrent MI after fibrinolytic therapy has been associated with increased early mortality in the acute MI setting, its relation to long-term mortality has not been fully explored.

METHODS: Mortality data were ascertained in 20,101 patients enrolled in the Thrombolysis In Myocardial Infarction (TIMI) 4, 9, and 10B and Intravenous NPA for the Treatment of Infarcting Myocardium Early (InTIME-II) acute MI trials.

RESULTS: The frequency of symptomatic recurrent MI during the index hospitalization was 4.2% (836/20,101). Recurrent MI during the index hospital period was associated with increased 30-day mortality (16.4% [137/836] vs. 6.2% [1,188/19,260], p < 0.001). Likewise, recurrent MI was associated with a sustained increase in mortality up to two years, even after adjustments were made for covariates known to be associated with mortality and recurrent MI (hazard ratio 2.11, p < 0.001). However, this higher mortality at 2 years was due to an early divergence in mortality by 30 days and was not due to a significant increase in late mortality between 30 days and 2 years (4.38% [31/707] vs. 3.76% [685/18,206], p = NS). Percutaneous coronary intervention during the index hospitalization was associated with a lower rate of in-hospital recurrent MI (1.6% vs. 4.5%, p < 0.001) and lower two-year mortality (5.6% vs. 11.6%, p < 0.001). Performance of coronary artery bypass graft surgery was also associated with a lower recurrent rate of MI (0.7% vs. 4.3%, p < 0.001) and lower two-year mortality rate (7.95% vs. 10.6%, p = 0.0008).

CONCLUSIONS: Early recurrent MI is associated with increased mortality up to two years. However, most deaths occur early, and the risk of additional deaths between the index hospital period and two years was not significantly increased among patients with recurrent MI. Percutaneous coronary intervention during the index hospitalization was associated with a lower risk of recurrent MI and a lower risk of two-year mortality.

Abbreviations and Acronyms   CABG   coronary artery bypass graft surgery   CI   confidence interval   CK   creatine kinase   HR   hazard ratio   InTIME-II   Intravenous NPA for the Treatment of Infarcting Myocardium Early trial   IQR   interquartile range   MI   myocardial infarction   PCI   percutaneous coronary intervention   rt-PA   recombinant tissue-type plasminogen activator   TIMI   Thrombolysis In Myocardial Infarction trial   TRS   Thrombolysis In Myocardial Infarction risk score   ULN   upper limit of normal

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