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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).

	Abstract

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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

We therefore sought to derive a simple clinical scoring system for prediction of short- and long-term mortality after primary PCI utilizing clinical, procedural, and angiographic information available at the time of intervention (including left ventricular function) and to validate this risk score against an independent study cohort. To this end, the databases from the two largest multicenter, randomized AMI trials of primary PCI to date were utilized for score derivation (the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications [CADILLAC] trial [11], n = 2,082] and subsequent validation (the Stent-Primary Angioplasty in Myocardial Infarction [Stent-PAMI] trial [12], n = 900).

	Methods

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The risk score was derived from the CADILLAC trial database, which comprises the largest and most comprehensive primary PCI database to date. In the CADILLAC trial, 2,082 patients of any age with AMI and symptoms lasting 30 min but 12 h who were not in cardiogenic shock at the time of presentation were enrolled (11). Additional major exclusion criteria included failed thrombolytic therapy (rescue PCI), the requirement for multivessel PCI during the index procedure, bleeding diatheses, cerebrovascular accident within the preceding two years, known hepatic or renal dysfunction, and the presence of serious co-morbidities with a life expectancy of less than one year. Angiographic inclusion criteria required a culprit artery with a reference diameter of 2.5 to 4.0 mm and lesion length <64 mm. After coronary arteriography and left ventriculography, patients were assigned randomly to either balloon angioplasty or stenting, each ± abciximab. Detailed clinical follow-up was obtained during hospitalization and at discharge, one month, six months, and one year.

For the validation set, the database from the Stent-PAMI trial was utilized, in which 900 eligible patients undergoing primary PCI were assigned randomly to stenting versus balloon angioplasty. The clinical and angiographic entry criteria, medications used, and procedural performance were similar between the Stent-PAMI and CADILLAC trials, except that abciximab was used in only 5% of patients in the Stent-PAMI trial compared to 53% in the CADILLAC trial, and the use of the MultiLink stent (Guidant, Santa Clara, California) in the CADILLAC trial compared with the heparin-coated Palmaz-Schatz stent in the Stent-PAMI trial afforded treatment of smaller vessels and longer lesions in the CADILLAC trial (12). The 30-day and 1-year mortality rates, however, were similar between the two studies.

Quantitative coronary angiography and left ventriculography.   Quantitative coronary angiography and left ventriculography were performed at the same independent core angiographic laboratory (the Cardiovascular Research Foundation, New York, New York) for both studies. Antegrade blood flow in the infarct artery was graded using the Thrombolysis In Myocardial Infarction (TIMI) scale (13). LVEF was calculated by the area-length method (14), and regional wall motion was determined by the centerline chord method (15).

End points and statistical analysis.   Categorical data were compared using the chi-square test. Continuous variables are presented as medians and interquartile ranges and were compared using the nonparametric Kruskal-Wallis test. Clinical outcomes are presented as Kaplan-Meier survival percentages and were compared using the log-rank test. For all analyses a two-sided p < 0.05 was considered statistically significant.

Baseline demographic, clinical, and angiographic parameters in the CADILLAC database were examined by univariate logistic regression analysis for their relation to one-year all-cause mortality, the primary end point for the current risk score. All variables in Table 1 were available for selection in this model. Left ventricular ejection fraction, hematocrit level, creatinine clearance, and age were dichotomized and treated as binary variables, based on previous work (6,16–18). Severe left ventricular systolic dysfunction was defined as an LVEF <0.40 (6). Based on World Health Organization criteria, anemia was defined as a baseline hematocrit level <39% for men and <36% for women (19). Creatinine clearance was calculated by the Cockcroft-Gault formula corrected for gender (20), and baseline renal insufficiency was defined as a creatinine clearance <60 ml/min (21). Significant univariate predictors of one-year mortality were subjected to a forward stepwise selection process (entry and exit criteria p = 0.05 and p = 0.10, respectively) in a sequence of "leave one out" jackknife procedures (n = 2,082). For variables selected in >85% of the samples, the odds ratio of one-year mortality rate was calculated in a final multivariate logistic regression analysis. Each of these variables was assigned a weighted score proportional to the multivariate odds ratio for one-year mortality. For the final score, three risk strata (low, intermediate, and high risk) were defined based on event rates for each individual score within the entire range resulting from the various combinations of weighted risk predictors. Event rates for each of these risk classes were calculated for the CADILLAC dataset and subsequently validated in the Stent-PAMI database. The discriminatory capacity of the model was assessed using the area under the receiver-operating characteristic (ROC) curve, and the difference between model-predicted and observed event rates (goodness-of-fit) was evaluated with the Hosmer-Lemeshow test (22) [p > 0.10 considered to indicate lack of deviation between the model and observed event rates (23)]. The prognostic utility of this 1-year risk score was also evaluated for all-cause mortality at 30 days. The areas under the ROC curves of the CADILLAC score and previous predictive models were compared using the nonparametric method of Delong et al. (24).

	Results

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Derivation and validation of the CADILLAC trial risk score: mortality prediction.   The observed rates of one-year mortality according to this scoring system are shown in Figure 1. After identifying the one-year mortality rate and the number of patients for individual scores, a risk score was developed based on the sum of weighted predictors present in each case. For simplicity, three risk strata were defined (low risk, score 0 to 2, encompassing 56.5% of the patients in the CADILLAC trial; intermediate risk, score 3 to 5, 23.8% of patients; and high risk, score 6, 19.7% of patients). The predictive accuracy of this scoring system for one-year mortality was as precise when applied to the Stent-PAMI trial validation dataset as for the CADILLAC trial derivation dataset (Fig. 2A). Moreover, the predictive accuracy of the risk score was retained when applied to the 30-day all-cause mortality end point in both the CADILLAC and Stent-PAMI trial datasets (Fig. 2B). Survival at various time points between 30 days and 1 year among CADILLAC patients stratified by risk class is shown in Figure 3, showing prognostic utility at all times throughout the follow-up period.

View larger version (25K): [in this window] [in a new window]   Figure 1 Integer scoring system and corresponding one-year mortality rates. LVEF = left ventricular ejection fraction; TIMI = Thrombolysis In Myocardial Infarction.

View larger version (27K): [in this window] [in a new window]   Figure 2 Score-based risk classification system with corresponding 1-year (A) and 30-day (B) mortality rates and discriminatory performance in the CADILLAC (solid bars) and Stent-PAMI (open bars) trial datasets.

View larger version (14K): [in this window] [in a new window]   Figure 3 Freedom from all-cause mortality among the CADILLAC trial patients stratified by risk class.

	Discussion

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Outcome prediction after primary PCI.   Accurate risk stratification after primary PCI is of importance in guiding patient management, resource utilization, and the design of clinical trials. Previous work has shown that the predictive capability of a risk model largely depends on the populations in which it was developed and to which it is applied (25). Most prior scores for mortality prediction after reperfusion therapy have been derived from thrombolytic therapy trials (2–5), whereas recent primary PCI risk models have differed from the present CADILLAC trial score in the risk factors included (8,9). Moreover, a comprehensive clinical and angiographic primary angioplasty risk model, subjected to strict validation against an independent study population, has not been reported.

The CADILLAC trial score, derived and externally validated using separate databases from the two largest multicenter randomized trials of primary PCI to date, was found to have an excellent predictive capacity for both 30-day and 1-year mortality (c statistics = 0.83 and 0.81 for 30-day mortality and 0.79 and 0.78 for 1-year mortality, respectively, for the CADILLAC trial derivation set and the Stent-PAMI trial validation set). Moreover, this risk score allowed the creation of risk strata in which 56% of patients had mortality rate of <1% at 1-year (similar to that expected in an age-matched controlled population), an intermediate risk population in which 24% of patients had 5-fold higher 1-year mortality (of 4.0% to 4.5%), and a high risk subgroup comprising 20% of patients with a 15-fold higher 1-year mortality (>12%). Thus, despite the fact that both trials excluded patients with cardiogenic shock, use of the risk score enables identification of a sizable cohort with a very poor long-term prognosis in whom close monitoring and aggressive therapy may be beneficial.

Predictors of mortality in the CADILLAC trial score and previous models.   Angiographic findings such as LVEF and the severity of coronary artery disease are of documented prognostic importance in AMI (7) and PCI (26) risk models. Models derived from thrombolytic therapy trials in which early cardiac catheterization was not routinely performed did not incorporate these variables into the formulation of risk scores, potentially limiting their power. A secondary advantage of primary PCI as a reperfusion modality is the ability to readily assess measures of baseline left ventricular function and the extent of coronary artery disease. However, recently reported PCI risk scores have either not utilized angiographic information (8) or have excluded LVEF (9) from the candidate variables.

The current analysis calls attention to the synergistic prognostic impact of both clinical and angiographic variables as well as factors that are potentially modifiable or that mandate specific intervention. The baseline measure of LVEF was identified as the most powerful long-term determinate of mortality and should thus be incorporated into risk models to obtain maximal predictive accuracy. Patients presenting with a low LVEF should be followed up closely for signs of incipient shock that might not be apparent at presentation (27). Aggressive medical management of patients with reduced left ventricular function is warranted to prevent sudden cardiac death and development of congestive heart failure (28–31). Of note, some operators do not routinely perform left ventriculography during the primary PCI procedure, and thus may not capture the full range of prognostic data available. Whether the predictive information from assessment of left ventricular function estimated by other modalities (e.g., echocardiography) or at a later time has the same prognostic utility as the LVEF obtained during baseline contrast ventriculography is unknown.

It is also worth considering intervention for other risk factors that were retained in the final multivariable model. Our findings regarding the impact of multivessel disease on survival emphasize the need for randomized clinical trials to determine whether acute multivessel intervention can improve prognosis in these high-risk patients, an approach to date not routinely recommended (32). Killip class at presentation, invariably a component of previous scores (2,4,8,9), remained an independent predictor of reduced short- and long-term survival in the current study apart from baseline LVEF and the extent of coronary artery disease, emphasizing the importance of the clinical examination for signs of mild to moderate heart failure even when left ventricular function is preserved. Anemia and renal insufficiency are recognized increasingly as conditions strongly predictive of mortality after AMI (16,17). The incremental prognostic value of these conditions was demonstrated in the current analysis and validated in an external dataset. Anemia represents a potentially modifiable risk factor, and in one report red blood cell transfusion was found to be associated with improved survival after AMI (33), an observation that warrants prospective investigation. Efforts are also warranted to minimize the occurrence of contrast nephropathy by adequate hydration and utilizing minimal amounts of low osmolar contrast (34), by consideration of n-acetylcysteine (35) and possibly alkalinization (36).

Of note, certain clinical and electrocardiographic predictors (e.g., diabetes, admission heart rate and blood pressure, electrocardiographic anterior AMI location, and/or left bundle branch block) that have been consistently present in previous scores that did not incorporate angiographic variables (2,4,5,8) are conspicuously absent from the final CADILLAC trial score. The prognostic impact of these clinical variables, which were significant correlates of survival by univariate analysis but not by multivariate analysis in this study, were likely contained within the stronger angiographic predictors of mortality in the CADILLAC trial score (e.g., LVEF at baseline, triple vessel disease). Supporting this contention is the report by De Luca et al. (9) in which consideration of multivessel disease and post-procedural TIMI flow grade excluded clinical variables other than age and Killip class from a risk model for 30-day mortality.

Study limitations.   Patients presenting with cardiogenic shock, with complex coronary anatomy (e.g., left main disease or bifurcation disease, and saphenous vein graft occlusion), and those undergoing rescue PCI after failed thrombolytic therapy were excluded from the CADILLAC trial; whether these factors would add additional incremental prognostic information or result in exclusion of other variables in the current score is unknown. Because the mortality rate in patients with cardiogenic shock remains very high even when aggressively managed by modern interventional strategies (37,38), this entity should probably be considered separately in the context of risk stratification. Operator experience and center volume (39) were not considered in the current analysis. Nonetheless, the current score was derived and validated using databases from large multicenter trials (using permissive inclusion criteria and with patients enrolled from 76 institutions in the CADILLAC trial and 62 institutions in the Stent-PAMI trial) so that it is likely to be widely applicable to a broad cross-section of patient care facilities. Measures of microvascular perfusion [e.g., resolution of ST-segment elevation and myocardial blush (40)] are absent from this as well as previous primary PCI risk score models (8,9), and may further improve prognostication beyond post-procedural TIMI flow grade. Additionally, the time from symptom onset to reperfusion was not an independent predictor of mortality in the current study. Recent data suggest that primary PCI within 3 h of symptom onset compared with longer intervals is associated with improved survival, but when the time to reperfusion exceeds 3 h, as was the case for most patients in the current analysis, further delays in reperfusion have minimal incremental effect on either early or late mortality (41). Thus, minimizing delays to PCI is always desirable, especially in patients presenting early after symptom onset. Finally, we chose to categorize the current score into only three risk classes, which likely resulted in an underestimation of the true predictive power of our model. Nevertheless, the predictive accuracy of the CADILLAC trial score compared favorably with that of previous scores that used a larger number of risk classes.

Conclusions and clinical implications.   Seven clinical and angiographic parameters routinely collected and readily available at baseline or procedural completion (age, Killip class, baseline anemia and renal insufficiency, triple vessel disease, LVEF, post-procedural TIMI flow grade) accurately predict 30-day and 1-year mortality rates after primary PCI when integrated in a simple risk scoring system. Our findings indicate that in the setting of contemporary catheter-based reperfusion therapy for AMI, the severity of coronary artery disease and evaluation of baseline LVEF importantly enhance risk stratification in concert with baseline demographic and clinical profiling. Further studies are warranted to determine whether novel pharmacologic, device-based, or surgical approaches can further improve the prognosis of the patients at highest risk after primary PCI as identified by the CADILLAC risk score.

	References

Top Abstract Methods Results Discussion References

 

1. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarctiona quantitative review of 23 randomised trials. Lancet 2003;361:13-20.[CrossRef][ISI][Medline]
2. Lee KL, Woodlief LH, Topol EJ, et al. Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarctionResults from an international trial of 41,021 patients. GUSTO-I Investigators. Circulation 1995;91:1659-1668.[ISI][Medline]
3. Fresco C, Carinci F, Maggioni AP, et al. Very early assessment of risk for in-hospital death among 11,483 patients with acute myocardial infarctionGISSI investigators. Am Heart J 1999;138:1058-1064.[CrossRef][ISI][Medline]
4. Morrow DA, Antman EM, Charlesworth A, et al. TIMI risk score for ST-elevation myocardial infarctiona convenient, bedside, clinical score for risk assessment at presentation: an intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation 2000;102:2031-2037.[Abstract/Free Full Text]
5. Morrow DA, Antman EM, Giugliano RP, et al. A simple risk index for rapid initial triage of patients with ST-elevation myocardial infarctionan InTIME II substudy. Lancet 2001;358:1571-1575.[CrossRef][ISI][Medline]
6. Zaret BL, Wackers FJ, Terrin ML, et al. Value of radionuclide rest and exercise left ventricular ejection fraction in assessing survival of patients after thrombolytic therapy for acute myocardial infarction: results of Thrombolysis In Myocardial Infarction (TIMI) phase II study. The TIMI Study Group J Am Coll Cardiol 1995;26:73-79.[Abstract]
7. Singh M, Reeder GS, Jacobsen SJ, Weston S, Killian J, Roger VL. Scores for post-myocardial infarction risk stratification in the community Circulation 2002;106:2309-2314.[CrossRef][ISI][Medline]
8. Addala S, Grines CL, Dixon SR, et al. Predicting mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PAMI risk score) Am J Cardiol 2004;93:629-632.[CrossRef][ISI][Medline]
9. De Luca G, Suryapranata H, Arnoud WJ, et al. Prognostic assessment of patients with acute myocardial infarction treated with primary angioplastyImplications for early discharge. Circulation 2004;109:2737-2743.[Medline]
10. de Feyter PJ, McFadden E. Risk score for percutaneous coronary interventionforewarned is forearmed. J Am Coll Cardiol 2003;42:1729-1730.[Free Full Text]
11. Stone GW, Grines CL, Cox DA, et al. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction N Engl J Med 2002;346:957-966.[Abstract/Free Full Text]
12. Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without stent implantation for acute myocardial infarctionStent Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 1999;341:1949-1956.[Abstract/Free Full Text]
13. TIMI Study Group The Thrombolysis In Myocardial Infarction (TIMI) trialPhase I findings. N Engl J Med 1985;312:932-936.[Medline]
14. Dodge HT, Sandler H, Ballew DW, Lord Jr JD. The use of biplane angiocardiography for the measurement of left ventricular volume in man Am Heart J 1960;60:762-776.[CrossRef][ISI][Medline]
15. Sheehan FH, Bolson EL, Dodge HT, Mathey DG, Schofer J, Woo HW. Advantages and applications of the centerline method for characterizing regional ventricular function Circulation 1986;74:293-305.[ISI][Medline]
16. Nikolsky E, Aymong ED, Halkin A, et al. Impact of anemia in patients with acute myocardial infarction undergoing primary percutaneous coronary interventionanalysis from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. J Am Coll Cardiol 2004;44:547-553.[Abstract/Free Full Text]
17. Sadeghi HM, Stone GW, Grines CL, et al. Impact of renal insufficiency in patients undergoing primary angioplasty for acute myocardial infarction Circulation 2003;108:2769-2775.[CrossRef][ISI][Medline]
18. Guagliumi G, Stone GW, Cox DA, et al. Outcome in elderly patients undergoing primary coronary intervention for acute myocardial infarctionresults from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. Circulation 2004;110:1598-1604.[CrossRef][ISI][Medline]
19. Nutritional anaemiasReport of a WHO scientific group. World Health Organ Tech Rep Ser 1968;405:5-37.[Medline]
20. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine Nephron 1976;16:31-41.[ISI][Medline]
21. K/DOQI clinical practice guidelines for chronic kidney diseaseevaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-S266.[CrossRef][ISI][Medline]
22. Harrell Jr FE, Lee KL, Mark DB. Multivariable prognostic modelsissues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 1996;15:361-387.[CrossRef][ISI][Medline]
23. Cutlip DE, Ho KK, Kuntz RE, Baim DS. Risk assessment for percutaneous coronary interventionour version of the weather report?. J Am Coll Cardiol 2003;42:1896-1899.[Free Full Text]
24. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curvesa nonparametric approach. Biometrics 1988;44:837-845.[CrossRef][ISI][Medline]
25. Morrow DA, Antman EM, Parsons L, et al. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3 JAMA 2001;286:1356-1359.[Abstract/Free Full Text]
26. Singh M, Lennon RJ, Holmes Jr DR, Bell MR, Rihal CS. Correlates of procedural complications and a simple integer risk score for percutaneous coronary intervention J Am Coll Cardiol 2002;40:387-393.[Abstract/Free Full Text]
27. Webb JG, Sleeper LA, Buller CE, et al. Implications of the timing of onset of cardiogenic shock after acute myocardial infarctiona report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? J Am Coll Cardiol 2000;36:1084-1090.
28. Khalil ME, Basher AW, Brown Jr EJ, Alhaddad IA. A remarkable medical storybenefits of angiotensin-converting enzyme inhibitors in cardiac patients. J Am Coll Cardiol 2001;37:1757-1764.[Abstract/Free Full Text]
29. Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunctionthe CAPRICORN randomised trial. Lancet 2001;357:1385-1390.[CrossRef][ISI][Medline]
30. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction N Engl J Med 2002;346:877-883.[Abstract/Free Full Text]
31. Hohnloser SH, Gersh BJ. Changing late prognosis of acute myocardial infarctionimpact on management of ventricular arrhythmias in the era of reperfusion and the implantable cardioverter-defibrillator. Circulation 2003;107:941-946.[CrossRef][Medline]
32. Roe MT, Cura FA, Joski PS, et al. Initial experience with multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction Am J Cardiol 2001;88:170-173.[CrossRef][ISI][Medline]
33. Wu WC, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction N Engl J Med 2001;345:1230-1236.[Abstract/Free Full Text]
34. Curhan GC. Prevention of contrast nephropathy JAMA 2003;289:606-608.[Free Full Text]
35. Birck R, Krzossok S, Markowetz F, Schnulle P, van der Woude FJ, Braun C. Acetylcysteine for prevention of contrast nephropathymeta-analysis. Lancet 2003;362:598-603.[CrossRef][ISI][Medline]
36. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonatea randomized controlled trial. JAMA 2004;291:2328-2334.[Abstract/Free Full Text]
37. Antoniucci D, Valenti R, Migliorini A, et al. Abciximab therapy improves survival in patients with acute myocardial infarction complicated by early cardiogenic shock undergoing coronary artery stent implantation Am J Cardiol 2002;90:353-357.[CrossRef][ISI][Medline]
38. Giri S, Mitchel J, Azar RR, et al. Results of primary percutaneous transluminal coronary angioplasty plus abciximab with or without stenting for acute myocardial infarction complicated by cardiogenic shock Am J Cardiol 2002;89:126-131.[CrossRef][ISI][Medline]
39. Vakili BA, Kaplan R, Brown DL. Volume-outcome relation for physicians and hospitals performing angioplasty for acute myocardial infarction in New York state Circulation 2001;104:2171-2176.[Abstract/Free Full Text]
40. van’t Hof AW, Liem A, Suryapranata H, Hoorntje JC, de Boer MJ, Zijlstra F. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Zwolle Myocardial Infarction Study Group Circulation 1998;97:2302-2306.[ISI][Medline]
41. Brodie BR, Cox DA, Stuckey TD, et al. How important is time to treatment with primary percutaneous coronary intervention for acute myocardial infarction (abstr)? J Am Coll Cardiol 2003;41(Suppl 5):368A.

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