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CLINICAL RESEARCH: PROGNOSTICATORS IN ACUTE INFARCTION

Long-Term Prognostic Value of ST-Segment Resolution in Patients Treated With Fibrinolysis or Primary Percutaneous Coronary Intervention

Results From the DANAMI-2 (DANish trial in Acute Myocardial Infarction-2)

Maria Sejersten, MD^_*,_*, Nana Valeur, MD, PhD^_*, Peer Grande, MD, DMSc^_*, Torsten Toftegaard Nielsen, MD, DMSc, Peter Clemmensen, MD, DMSc^_* for the DANAMI-2 Investigators

^_* Heart Center, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Faculty of Health Sciences, Copenhagen, Denmark
Department of Cardiology, Skejby University Hospital, Aarhus, Denmark

Manuscript received November 3, 2008; revised manuscript received March 19, 2009, accepted March 24, 2009.

^_* Reprint requests and correspondence: Dr. Maria Sejersten, Department of Cardiology B, 2142, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark (Email: msejersten{at}hotmail.com).

Objectives: The purpose of this study was to determine the prognostic value of ST-segment resolution after primary percutaneous coronary intervention (pPCI) versus fibrinolysis.

Background: Resolution of the ST-segment has been used as a surrogate end point in trials evaluating reperfusion in acute myocardial infarction; however, its prognostic significance may be limited to patients treated with fibrinolysis.

Methods: In the DANAMI-2 (DANish trial in Acute Myocardial Infarction-2) substudy, including 1,421 patients, the ST-segment elevation at baseline, pre-intervention, 90 min, and 4 h was assessed. The ST-segment resolution was grouped as follows: 1) complete 70%; 2) partial 30% to <70%; and 3) no resolution <30%. End points were 30-day and long-term mortality and reinfarction.

Results: The ST-segment resolution at 90 min was more pronounced after pPCI (median 60% vs. 45%, p < 0.0001), and a catch-up phenomenon was observed at 4 h. In the fibrinolysis group, 30-day and long-term mortality rates were significantly higher among patients without ST-segment resolution, whereas reinfarction rates were higher with complete ST-segment resolution. The ST-segment resolution was not associated with the 2 end points in the pPCI group. By multivariate analysis, ST-segment resolution at 4 h was an independent predictor of lower mortality, but higher reinfarction rates among patients receiving fibrinolytic therapy.

Conclusions: The ST-segment resolution at 90 min was more complete after pPCI, suggesting better epicardial and microvascular reperfusion, whereas no difference between treatment strategies was seen at 4 h. The ST-segment resolution at 4 h correlated with decreased mortality, but increased reinfarction rates among patients receiving fibrinolytic therapy, whereas no association was seen for patients receiving pPCI. Consequently, 4-h ST-segment resolution remains an important prognosticator after fibrinolysis, but may be overemphasized as a surrogate end point after pPCI.

Key Words: primary percutaneous coronary intervention • fibrinolysis • ST-segment elevation myocardial infarction • ST-segment resolution • outcome

Abbreviations and Acronyms   ECG = electrocardiogram   IQR = interquartile range   PCI = percutaneous coronary intervention   pPCI = primary percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction   ST = sum of ST-segment elevation

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