Long-Term Mortality of Patients Undergoing Cardiac Catheterization for ST-Elevation and Non-ST-Elevation Myocardial Infarction

Abstract

Background-There are limited contemporary data comparing long-term outcomes after cardiac catheterization for ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). Methods and Results-We studied patients undergoing cardiac catheterization for STEMI (nϭ2413) and NSTEMI (nϭ1974) between 1999 and 2005 with at least 1 significant coronary lesion Ն75%. We compared adjusted mortality rates over restricted time intervals and the differential impact of early revascularization on mortality stratified by ST-elevation status. Between 1999Between and 2007Between , 1274 patients died, with a median follow-up of 4 years. A piece-wise analysis showed a higher adjusted mortality risk for STEMI during the first 2 months (adjusted hazard ratio, 1.85; 95% confidence interval, 1.45 to 2.38) and a lower adjusted mortality risk for STEMI after 2 months (adjusted hazard ratio, 0.68; 95% confidence interval, 0.59 to 0.83). Compared with late or no revascularization, early revascularization was associated with a lower adjusted risk of mortality for both STEMI (adjusted hazard ratio, 0.73; 95% confidence interval, 0.58 to 0.90) and NSTEMI (adjusted hazard ratio, 0.76; 95% confidence interval, 0.65 to 0.89) (P for interactionϭ0.22). Conclusions-Among a contemporary cohort of acute MI patients with significant coronary disease during cardiac catheterization, STEMI was associated with a higher risk of short-term mortality, but NSTEMI was associated with a higher risk of long-term mortality. Early revascularization was associated with a similar improvement in long-term outcomes for both STEMI and NSTEMI. These data suggest that in clinical investigations of early revascularization among patients with NSTEMI, extended follow-up may be necessary to demonstrate treatment benefit. (Circulation. 2009;119:3110-3117.)Key Words: acute coronary syndrome Ⅲ angioplasty Ⅲ catheterization Ⅲ coronary disease Ⅲ electrocardiography Ⅲ myocardial infarction Ⅲ revascularization M yocardial infarction (MI) remains a leading cause of mortality worldwide. 1 ST-elevation MI (STEMI) is associated with a higher incidence of persistent and total coronary occlusion, whereas non-STEMI (NSTEMI) is associated with a greater severity and burden of coronary artery disease (CAD). 2 The contemporary definition of MI, introduced in 1999 3 and revised in 2007 4 , focused on circulating biomarkers, predominantly troponin, that detect myocardial necrosis with high sensitivity. However, most of the prior studies that investigated long-term outcomes on the basis of MI classification focused on non-Q-wave MI versus Q-wave MI comparisons, 5-20 whereas fewer contemporary studies have used the newer troponin-based MI definition and classification system (STEMI versus NSTEMI). [21][22][23][24] Clinical Perspective on p 3117Several other potential differences exist between patients in current practice and those in historical studies. In contemporary practice, the diagnosis is often based on a history of chest pain and elevated biomarkers rather than ECG finding...

Comparison of Risk Prediction With the CKD‐EPI and MDRD Equations in Non–ST‐Segment Elevation Acute Coronary Syndrome

“…These patients tend to be older, have more comorbidity (including worse renal function), and have worse long-term prognosis compared with ST-segment elevation ACS patients. 38 Therefore, accurate long-term risk stratification of NSTE-ACS patients is even more crucial. In contrast with these results,Åkerblom et al 12 failed to demonstrate a benefit in predicting long-term mortality with a CysC-based equation in the large ACS population enrolled in the Platelet Inhibition and Patient Outcomes (PLATO) study.…”

Long-Term Outcomes of Non-ST-Elevation Myocardial Infarction Without Creatine Kinase Elevation ― The J-MINUET Study ―

“…Second, patients with NSTEMI have more extensive coronary artery disease. 6, 13 Asakura et al 16 studied patients who underwent coronary angioscopy in all 3 coronary arteries at 1 month after MI. They showed all 3 major coronary arteries, both infarct-related and non-related arteries, were widely diseased and had multiple yellow plaques, suggesting a pan-coronary process of vulnerable plaque development in patients with MI.…”

“…In these studies, NSTEMI-CK, formerly diagnosed as UA, was include in NSTEMI. 12, 13 In patients with NSTEMI, less extensive infarct, undetectable by serum CK measurement, was associated with favorable short-term outcomes.…”

Acute Myocardial Infarction

“…Traditionally, patients with NSTEMI have a substantially lower early mortality than those with STEMI, but a higher risk of long-term mortality, likely explained by more frequent risk factors and comorbidities, and a greater burden of coronary artery disease. [7][8][9] The improvement in early outcomes up to the early 2010s has been attributed to changes in patient populations, more frequent use of revascularization procedures, and increased use of recommended medications. 5,6,[10][11][12] Since 2010, however, little information is available on early outcomes in real-world settings, although the use of percutaneous coronary interventions (PCIs) has continued to increase and newer antithrombotic agents have become available and are now widely used.…”