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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Prediction of Mortality After Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

The CADILLAC Risk Score

Amir Halkin, MD^_*, Mandeep Singh, MD, Eugenia Nikolsky, MD^_*, Cindy L. Grines, MD, FACC, James E. Tcheng, MD, FACC, Eulogio Garcia, MD^||, David A. Cox, MD, FACC^¶, Mark Turco, MD, FACC^#, Thomas D. Stuckey, MD, FACC^_**, Yingo Na, MSc^_*, Alexandra J. Lansky, MD, FACC^_*, Bernard J. Gersh, MB, ChB, DPhil, FACC, William W. O’Neill, MD, FACC, Roxana Mehran, MD, FACC^_* and Gregg W. Stone, MD, FACC^_*,_*

^_* Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
Mayo Clinic and Foundation, Rochester, Minnesota
William Beaumont Hospital, Royal Oak, Michigan
Duke Clinical Research Institute, Durham, North Carolina
^|| Hospital Gregorio Maranon, Madrid, Spain
^¶ Mid Carolina Cardiology, Charlotte, North Carolina
^# Washington Adventist Hospital, Tacoma Park, Maryland
^_** Moses Cone Hospital, Greensboro, North Carolina

Manuscript received October 25, 2004; revised manuscript received January 19, 2005, accepted January 19, 2005.

^_* Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, 55 East 59th Street, 6th Floor, New York, New York 10022 (Email: gstone{at}crf.org).

OBJECTIVES: We sought to develop a simple risk score for predicting mortality after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI).

BACKGROUND: Accurate risk stratification after primary PCI is important. Previous risk scores after reperfusion therapy have incorporated clinical ± angiographic variables but have not considered baseline left ventricular function. Moreover, prior studies have not been validated against independent databases or studies.

METHODS: The databases from the two largest multicenter, randomized AMI trials of primary PCI were utilized for score derivation (the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications [CADILLAC] trial, n = 2,082) and subsequent validation (the Stent-Primary Angioplasty in Myocardial Infarction [Stent-PAMI] trial, n = 900). Logistic regression and the jackknife procedure were used to select correlates of one-year mortality that were subsequently weighted and integrated into an integer scoring system.

RESULTS: Seven variables selected from the initial multivariate model were weighted proportionally to their respective odds ratio for one-year mortality (age >65 years [2 points], Killip class 2/3 [3 points], baseline left ventricular ejection fraction <40% [4 points], anemia [2 points], renal insufficiency [3 points], triple-vessel disease [2 points], and post-procedural Thrombolysis In Myocardial Infarction flow grade [2 points]). Three strata of risk were defined (low risk, score 0 to 2; intermediate risk, score 3 to 5; and high risk, score 6) with excellent prognostic accuracy for survival in the derivation and validation sets (c statistics = 0.83 and 0.81 for 30-day mortality and 0.79 and 0.78 for 1-year mortality, respectively).

CONCLUSIONS: In AMI patients treated with primary PCI, seven risk factors readily available at the time of intervention accurately predict short- and long-term mortality. Of note, measurement of baseline left ventricular function is the single most powerful predictor of survival and should be incorporated into risk score models.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CADILLAC = Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications trial   CI = confidence interval   LVEF = left ventricular ejection fraction   OR = odds ratio   PCI = percutaneous coronary intervention   ROC = receiver-operating characteristic   Stent-PAMI = Stent-Primary Angioplasty in Myocardial Infarction trial

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