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Relative value of clinical variables, treadmill stress testing, and Holter ST monitoring for postinfarction risk
R N Stevenson1, P Wilkinson, B G Marchant
1Department of Cardiology, London Chest Hospital, United Kingdom.
Insights
Holter ST shift monitoring is a strong predictor of recurrent events after thrombolysis, outperforming clinical assessment and treadmill stress testing for postinfarction risk stratification.
Area of Science:
- Cardiology
- Clinical Medicine
- Medical Diagnostics
Background:
- Risk stratification is crucial for patients postmyocardial infarction treated with thrombolysis.
- Early recurrent events can occur before standard postinfarction assessments are feasible.
Purpose of the Study:
- To compare the effectiveness of clinical assessment, treadmill stress testing, and Holter ST analysis for postinfarction risk stratification.
- To identify the most reliable predictor of recurrent events in patients treated with thrombolysis.
Main Methods:
- A cohort of 256 patients treated with thrombolysis underwent early Holter ST monitoring.
- Multivariate analysis was used to assess the predictive value of clinical variables (Killip class), Holter ST shift, and treadmill stress testing outcomes.
- Recurrent events (death, reinfarction, unstable angina) and revascularization were tracked over an 8-month follow-up.
Main Results:
- Holter ST shift and Killip class > or = 2 were independent predictors of recurrent events.
- Holter ST shift, particularly with a cumulative duration > 60 minutes, was the strongest predictor.
- In patients who completed stress testing, Killip class was the sole independent predictor of event-free survival; however, Holter ST shift predicted revascularization.
Conclusions:
- Holter ST shift is a powerful independent predictor of adverse outcomes after thrombolysis.
- Early recurrent events are common, often occurring before treadmill stress testing can be performed.
- Holter monitoring provides valuable early risk stratification data in postinfarction patients treated with thrombolysis.
Abstract:
The aim of this study was to compare the roles of clinical assessment, treadmill stress testing, and Holter ST analysis for postinfarction risk stratification in patients treated with thrombolysis. The study group consisted of 256 consecutive patients, all of whom underwent Holter ST monitoring early (mean 83 hours, range 48 to 180) after admission. Of these, 12 were excluded from the analysis either because Holter recordings were of insufficient quality (n = 6), or because reinfarction occurred within 24 hours of monitoring (n = 6). In the remaining 244 patients, 43 sustained a recurrent event (death, reinfarction, unstable angina) over the 8-month (range 3 to 12) follow-up period, and an additional 14 patients required revascularization. At multivariate event-free survival analysis, Killip class > or = 2 and Holter ST shift were independently predictive of the outcome. The strongest predictor was Holter ST shift at a cumulative duration of > 60 minutes. Of the 232 patients eligible for stress testing (12 sustained an event between Holter monitoring and the scheduled stress test), 196 were able to perform the test. The variable "inability to perform a stress test" was not independently predictive of outcome and did not influence the multivariate analysis. When clinical, Holter, and stress test variables were taken into account in patients who performed a stress test, Killip class was the only independent predictor of outcome (event-free survival). When revascularization was included as an end point, Holter ST shift was the only independent predictor of outcome. In conclusion, a significant proportion of recurrent events after thrombolysis occurs very early, before stress testing can be performed.(ABSTRACT TRUNCATED AT 250 WORDS)