CLINICAL RESEARCH: ACUTE CORONARY SYNDROME
Short- and Long-Term Risk Stratification in Acute Coronary Syndromes
The Added Value of Quantitative ST-Segment Depression and Multiple Biomarkers
Cynthia M. Westerhout, MSc*, ,*,
Yuling Fu, MD*,
Michael S. Lauer, MD, FACC ,
Stefan James, MD, PhD ,
Paul W. Armstrong, MD, FACC*,
Eyad Al-Hattab, MD,
Robert M. Califf, MD, FACC||,2,
Maarten L. Simoons, MD, FACC,
Lars Wallentin, MD, PhD, FACC,1,
Eric Boersma, PhD on behalf of the GUSTO-IV ACS Trial Investigators
* University of Alberta, Edmonton, Canada
Erasmus Medical Center, Rotterdam, the Netherlands
Cleveland Clinic Foundation, Cleveland, Ohio
University of Uppsala, Uppsala, Sweden
|| Duke Clinical Research Institute, Durham, North Carolina
Manuscript received January 1, 2006;
revised manuscript received March 28, 2006,
accepted April 24, 2006.
* Reprint requests and correspondence: Ms. Cynthia M. Westerhout, 214 Heritage Medical Research Centre, University of Alberta, Edmonton, Alberta, T6G 2S2 Canada. (Email: cindy.westerhout{at}ualberta.ca).
OBJECTIVES: The purpose of this study was to develop 30-day and 1-year risk stratification models for non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients that incorporate quantitative ST-segment depression and novel biomarkers.
BACKGROUND: Several novel biomarkers have changed the risk profile of ACS; thus, the reassessment of traditional indicators such as ST-segment depression in this new context is warranted.
METHODS: Multivariable logistic regression was used to identify significant predictors of 30-day death and death/myocardial infarction (MI) and 1-year mortality in 7,800 NSTE-ACS patients enrolled in the GUSTO-IV (Global Utilization of Strategies to Open Occluded Arteries-IV ACS) trial between 1998 and 2000.
RESULTS: Among all other predictors, the degree of ST-segment depression had the highest prognostic value for 30-day death, 30-day death/MI, and 1-year death. Troponin T (TnT), creatinine clearance, N-terminal pro-brain natriuretic peptide (NT-proBNP), heart rate, and age were also highly influential on adverse outcomes. Unlike TnT and NT-proBNP, C-reactive protein was only predictive of long-term death. In contrast to mortality, the contribution of TnT to predicting 30-day death/MI increased, whereas NT-proBNP’s role was attenuated. The discriminatory power was excellent (c-index [adjusted for over-optimism]: 0.82 [30-day death]; 0.72 [30-day death/MI]; 0.81 [1-year]).
CONCLUSIONS: In this large contemporary study of NSTE-ACS patients, novel insights into risk stratification were observed—in particular, the utility of quantitative ST-segment depression and multiple biomarkers. Collection of these indicators in future NSTE-ACS populations is recommended to evaluate generalizability and clinical application of these findings.
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Abbreviations and Acronyms
| | CRP = C-reactive protein | | ECG = electrocardiogram | | NSTE-ACS = non–ST-segment elevation acute coronary syndrome | | NT-proBNP = N-terminal pro-brain natriuretic peptide | | PCI = percutaneous coronary intervention | | TnT = cardiac troponin T |
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