Prognostic Assessment of Patients With Acute Myocardial Infarction Treated With Primary Angioplasty

Abstract

Background-The aim of this study was to create a practical score for risk stratification in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty and to assess the feasibility of early discharge in low-risk patients. Methods and Results-A prognostic score was built according to 30-day mortality rates in 1791 patients undergoing primary angioplasty for STEMI. For the identified low-risk patients without any contraindication to early discharge, we estimated and compared the costs of conventional care (prolonged 24-hour hospitalization) with the costs of shifting the care from inpatient to outpatient setting (early discharge) between 48 and 72 hours. Independent predictors of 30-day mortality included in the score were age, anterior infarction, Killip class, ischemic time, postprocedural Thrombolysis In Myocardial Infarction (TIMI) flow, and multivessel disease. This score was able to identify a large cohort (73.4%) of low-risk (score Յ3) patients, with a good discriminatory capacity (c statisticϭ0.907). The mortality rate was 0.1% at 2 days and 0.2% between 2 and 10 days in patients with a score Յ3. The incremental cost-effectiveness ratio for late discharge in low-risk patients was estimated at €1949.33. Therefore, this policy would save 1 life per 1097 low-risk patients, at additional costs of €194 933.33, in comparison with an early discharge policy. Conclusions-This score is a practical and useful index for risk stratification after primary angioplasty for STEMI, with a significant impact on clinical decision-making and the related costs. It reliably identifies a large group of patients at very low risk, who may safely be discharged early after primary angioplasty.

Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort

“…According the established cutoff values,12, 17, 18, 20 IMR >40 was measured in 102 of 261 patients (39.1%) and was able to identify all 17 patients (sensitivity: 100%) with early major cardiac complications following an acute myocardial infarction, with a specificity of 65.2% (Figure 2). The individual complications are shown in Table 2.…”

“…Current international guidelines suggest that PPCI patients with a “low‐risk of complications” might be candidates for non‐ICU admission5 and early discharge2 and mention the PAMI‐II and Zwolle scores as useful risk‐stratification tools 17, 18…”

“…This information is available at the time of completing the PPCI and may apply to ≈60% of STEMI patients, based on our cohort, and would have major implications on the ICU admission rate 31. In addition, this approach may improve patient experience32 and shorten the overall hospital stay by facilitating early discharge, with consequent reduction in hospital costs 17, 18. Furthermore, those patients with an IMR >40 represent a group at very high risk of early in‐hospital complications and may benefit from even more intensive monitoring.…”

“…The Zwolle score defines STEMI patients as low risk if they have ≤3 of 16 points based on Killip class, postprocedural TIMI flow, age <60 years, ischemic time <4 hours, and absence of 3‐vessel disease or anterior myocardial infarction18 (Table S1). …”

Predictors of ventricular tachyarrhythmia in high-risk myocardial infarction patients treated with primary coronary intervention

“…Risk scores for stratifying patients with regard to suitability for early discharge have been developed; however, implementation of these risk scores into clinical practice remains cumbersome. 24 Our data suggest that early discharge should be discouraged in patients with suspected larger infarction, as they have a higher rate of VT early after PCI. On the other hand, patients with small infarctions, particularly when associated with TIMI 2-3 flow at the initial angiography, are at low risk for VT and do not require rhythm monitoring for prolonged periods.…”