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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.

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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