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Published on: August 16, 2019
Dynamic modeling of 90-day mortality in ST-elevation myocardial infarction patients undergoing primary percutaneous
Cynthia M Westerhout1, Karen S Pieper, Stefan K James
1Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
Insights
Dynamic risk models for ST-elevation myocardial infarction (STEMI) show that patient risk changes significantly in the hours after primary percutaneous coronary intervention (PCI). These evolving models improve mortality prediction and aid clinical decisions.
Area of Science:
- Cardiology
- Clinical Risk Prediction
Background:
- Dynamic risk models are crucial for updating the risk profiles of ST-elevation myocardial infarction (STEMI) patients during the acute phase.
- These models have significant implications for both clinical practice and future research in cardiovascular medicine.
Purpose of the Study:
- To develop and validate multivariable survival models for predicting 90-day mortality in STEMI patients undergoing primary percutaneous coronary intervention (PCI).
- To assess how risk profiles and the importance of various clinical factors evolve at different time points (baseline, 2, 24, and 96 hours) post-PCI.
Main Methods:
- Developed multivariable survival models using data from 5,745 STEMI patients in the APEX-AMI trial.
- Incorporated factors such as coronary thrombolysis in myocardial infarction flow grade, ST-elevation residual post-PCI, and in-hospital events.
- Evaluated model performance using the c-index at multiple time points.
Main Results:
- The 90-day mortality rate was 4.7%, with cumulative mortality occurring by 2, 24, and 96 hours at 8%, 22%, and 40%, respectively.
- While age and systolic blood pressure remained important, the influence of heart rate, Killip class, and creatinine decreased over time.
- Markers of coronary reperfusion and in-hospital events like shock and heart failure became increasingly significant predictors.
- The model's predictive accuracy (c-index) improved from 0.819 at baseline to 0.847 at 96 hours.
- The proportion of patients classified as "low-risk" (<1.1% 90-day mortality) increased from 20% to 49% over the observed periods.
Conclusions:
- This novel approach using a series of dynamic models effectively demonstrates the changing nature of mortality risk in STEMI patients post-PCI.
- The findings highlight the utility of time-varying risk assessment for improving clinical decision-making and patient management.
- This dynamic risk stratification may enhance understanding of STEMI progression and inform targeted interventions.
Aims:
Dynamic risk models update the risk profile of ST-elevation myocardial infarction (STEMI) patients over the acute period following the event and have implications to clinical practice and research.
Methods And Results:
Multivariable survival models were developed in 5,745 STEMI patients undergoing primary percutaneous coronary intervention (PCI) enrolled in the APEX-AMI trial to predict 90-day mortality from 4 clinically relevant times: baseline, 2 hours, 24 hours, and 96 hours. Culprit coronary thrombolysis in myocardial infarction flow grade, 30-minute post-PCI worst-lead ST-elevation residual, and in-hospital clinical events were considered in the models. The 90-day mortality was 4.7%; the cumulative proportion of mortality occurring within 2, 24, and 96 hours was 8%, 22%, and 40% respectively. Relative to the baseline risk factors, age and systolic blood pressure remained highly ranked in the post-baseline models. However, the relative importance of heart rate, Killip class, and creatinine declined, whereas markers of coronary reperfusion and in-hospital events (shock, congestive heart failure) became increasingly influential. The c-index increased from 0.819 at baseline to 0.847 at 96 hours. Over the forecasting periods, the proportion of "low-risk" (<1.1% 90-day mortality) patients increased from 20% to 49%. This approach derived from an unfolding series of models reveals the shifting levels of mortality risk from baseline to 96 hours.
Conclusion:
This novel approach in STEMI patients undergoing primary PCI demonstrates the dynamic nature of risk over time and may prove useful in understanding risk and in clinical decision making.
