Noninvasive Risk Assessment Early After a Myocardial InfarctionThe REFINE Study
Derek V. Exner, MD, MPH*, ,1,*,
Katherine M. Kavanagh, MD*, ,
Michael P. Slawnych, MD, PhD*,
L. Brent Mitchell, MD*,
Darlene Ramadan, BSN*,
Sandeep G. Aggarwal, MD*,
Catherine Noullett, RN*,
Allie Van Schaik, RN,
Ryan T. Mitchell, BSc*,
Mariko A. Shibata, BSc*,
Sajad Gulamhussein, MD,
James McMeekin, MD*,
Wayne Tymchak, MD,
Gregory Schnell, MD*,
Anne M. Gillis, MD*,2,
Robert S. Sheldon, MD, PhD*,
Gordon H. Fick, PhD,
Henry J. Duff, MD*,2 for the REFINE Investigators
* Libin Cardiovascular Institute of Alberta, Calgary, Canada
Department of Community Health Sciences, University of Calgary, Calgary, Canada
Department of Medicine, University of Alberta, Edmonton, Canada.
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Figure 1 Patient Selection and Outcomes
A total of 322 patients with residual left ventricular dysfunction in the initial week after a myocardial infarction completed serial testing. They were enrolled from a larger population, most of whom were deemed ineligible due to preserved left ventricular function, a serious comorbid illness, or an inability or unwillingness to undergo serial testing. During 47 months of follow-up, 30 deaths were observed. Of these, 22 were categorized as cardiac and 17 as cardiac arrhythmic. Additionally, 7 resuscitated cardiac arrests occurred, only 2 of which were in patients with an implantable cardioverter-defibrillator (ICD) at the time of the event. Events comprising the primary outcome are shown in blue.
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Figure 2 Predictive Value in Subgroups
The unadjusted risk of the primary outcome of cardiac death or resuscitated cardiac arrest (A) and the secondary outcomes of fatal or nonfatal cardiac arrest (B) and all-cause mortality (C) for patients with versus without both abnormal heart rate turbulence and abnormal Holter repolarization alternans are shown. The central estimate and 95% confidence interval for the hazard ratio in subgroups and overall are shown. LVEF = left ventricular ejection fraction; MI = myocardial infarction.
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Figure 3 Risk Dichotomization
The risk of the primary outcome of cardiac death or resuscitated cardiac arrest (A) and secondary outcomes of fatal or nonfatal cardiac arrest (B) and all-cause mortality (C) among patients with impaired autonomic tone, measured using either baroreflex sensitivity or heart rate turbulence, plus abnormal repolarization alternans and an ejection fraction below 0.50 versus the remaining patients are shown. Numbers of patients in each group at the time points are indicated below each graph. TWA = T-wave alternans; other abbreviations as in Figure 2.
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