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Risk assessment in patients with acute myocardial infarction treated with thrombolytic therapy
M Jensen-Urstad1, B A Samad, K Jensen-Urstad
1Department of Cardiology, Karolinska Hospital, Karolinska Institute, Stockholm, Sweden. mats.jensen-urstad@medks.ki.se
Insights
Clinical risk assessment, exercise stress tests, and left ventricular function estimates are key for predicting outcomes in patients after acute myocardial infarction (AMI) treated with thrombolysis. Advanced tests offer limited additional prognostic value for low-to-medium risk patients.
Area of Science:
- Cardiology
- Internal Medicine
- Clinical Research
Background:
- Noninvasive methods offer prognostic insights post-acute myocardial infarction (AMI).
- Clinical decision-making in the immediate post-MI period requires clear prognostic tools.
- This study evaluated prognostic methods in AMI patients treated with thrombolysis.
Purpose of the Study:
- To clarify the practical utility of various noninvasive methods for risk stratification in the early post-MI period.
- To identify which prognostic indicators are most valuable for clinical decision-making after thrombolytic therapy for AMI.
- To assess the added value of advanced noninvasive techniques beyond standard clinical assessments.
Main Methods:
- 100 patients treated with thrombolysis for AMI were studied 5-8 days post-admission.
- Evaluated methods included clinical scoring, SPECT, echocardiography, radionuclide angiography, exercise stress tests, and Holter ECG with HRV analysis.
- Follow-up for mortality, nonfatal reinfarction, and revascularization needs occurred over 12 months.
Main Results:
- Inability to complete an exercise test and ejection fraction < 40% were significant predictors of mortality.
- No tested method reliably predicted nonfatal reinfarction.
- Positive exercise stress tests, ST-depressions on Holter ECG, and reversible perfusion defects on SPECT predicted the need for revascularization.
Conclusions:
- Clinical risk assessment, exercise stress testing, and left ventricular function estimates provide essential prognostic information in thrombolysed MI patients.
- Advanced noninvasive tests like adenosine-SPECT, HRV analysis, and Holter monitoring do not significantly enhance risk stratification for low-to-medium risk patients.
- Standard, readily available methods are sufficient for prognostication in many post-MI patients receiving thrombolysis.
Objective:
Several noninvasive methods have prognostic information regarding mortality and new coronary events after an acute myocardial infarction (AMI). The practical for clinical decision-making in the immediate postmyocardial infarction (MI) period is, however, less evident. We investigated consecutive patients with AMI treated with thrombolysis to further clarify this issue.
Design:
A total of 100 patients (27% women) aged 64 +/- 9 years (mean +/- SD) were studied. Risk assessment based on a clinical score system, myocardial perfusion scintigraphy single photon emission computed tomography (SPECT) at rest and during adenosine stress, echocardiography, radionuclide angiography, symptom-limited exercise stress test, and 24-h Holter ECG recording with ST-analysis and analysis of heart rate variability (HRV) were performed 5-8 days after hospital admission. Mortality, nonfatal reinfarction, and the need for revascularization were followed during 12 months.
Setting:
A university hospital.
Results:
A total of 6 patients died, seven had a nonfatal reinfarction, and 23 were revascularized. Inability to perform an exercise test (P = 0.004) and an ejection fraction (EF) < 40% (P = 0.002) were the only parameters separating those who died from the survivors. No method could predict a nonfatal reinfarction. Patients suffering either death or nonfatal reinfarction had a clinical risk assessment score 2 points higher (8.8 vs. 6.7, P = 0.05) than the group without such events. A positive symptom-limited exercise stress test (P = 0.027), ST-depressions on Holter ECG (P = 0.04), and reversibility on myocardial perfusion scintigraphy (P = 0.029) predicted the need for revascularization.
Conclusion:
Risk assessment based on clinical information, exercise stress testing, and an estimate of left ventricular function (e.g. via echocardiography) contribute with prognostic information in thrombolysed MI-patients. Additional noninvasive investigations such as adenosine-SPECT, analysis of HRV, and Holter-monitoring do not add to these commonly available tools in risk stratification of subjects at low to medium risk.