CARDIOVASCULAR MEDICINE

Associations between ST depression, four year mortality, and in-hospital revascularisation in unselected patients with non-ST elevation acute coronary syndromes

T A Hyde, J K French, C-K Wong, C Edwards, R M L Whitlock, H D White

Cardiology Department, Green Lane Hospital, Auckland, New Zealand

Correspondence to:
Correspondence to:
Dr Tom Hyde, Department of Cardiology, The London Chest Hospital, London E2 9JX, UK;
tom.hyde{at}bartsandthelondon.nhs.uk

Objective: To determine the associations between changes on the presenting ECG, in-hospital revascularisation, and four year mortality in patients with non-ST elevation acute coronary syndromes.

Design: Prospective evaluation of all consecutive patients admitted in 1993 to the Green Lane Hospital coronary care unit, Auckland, New Zealand. Late follow up was undertaken at a median of 52 months. The ECGs were analysed after the hospital admission.

Setting: Tertiary referral centre with direct local coronary care unit admissions.

Interventions: Patients underwent physician recommended in-hospital revascularisation or initial conservative management.

Results: The four year survival was 88% in the 115 patients who underwent revascularisation (65 (19%) percutaneous and 53 (16%) surgical revascularisation), compared with 75% in 316 patients managed conservatively (p = 0.024). Four year survival for patients undergoing revascularisation versus initial conservative management with respect to ECG groups was: no ECG changes (n = 101), 97% v 92% (p = 0.35); T wave inversion or 0.5 mm ST depression (n = 108), 89% v 78% (p = 0.18); ST depression 1 mm (n = 122), 80% v 58% (p = 0.014); ² = 29, p < 0.001 for the linear trend across the groups. On multivariate analysis, independent predictors of four year mortality were: age (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01 to 1.08; p = 0.0046); ECG group (OR 1.88, 95% CI 1.21 to 2.95; p = 0.043); radiological pulmonary oedema (OR 2.81, 95% CI 1.18 to 7.05; p = 0.025); and revascularisation (OR 0.43, 95% CI 0.20 to 0.90; p = 0.023).

Conclusions: Among unselected patients with non-ST elevation acute coronary syndromes, in-hospital revascularisation is associated with decreased mortality at up to four years after admission. This association appears greater in patients with ST depression of 1 mm on the presenting ECG.

Keywords: mortality; revascularisation; acute coronary syndrome

Abbreviations: CABG, coronary artery bypass graft; CK, creatine kinase; FRISC II, Fragmin and fast revascularisation during instability in coronary artery disease; IQR, interquartile range; MATE, medicine v angiography in thrombolytic exclusion trial; OR, odds ratio; PRISM, platelet receptor inhibition in ischaemic syndrome management; RITA, randomised interventional trial of unstable angina; SHOCK, should we emergently revascularise occluded coronaries for cardiogenic shock; TACTICS, comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban; TIMI, thrombolysis in myocardial infarction trial; TRUCS, treatment of refractory unstable angina in geographically isolated areas without cardiac surgery; VANQWISH, VA non-Q-wave infarction strategies in hospital; VINO, value of first day angiography/angioplasty in evolving non-ST elevation myocardial infarction: an open multicentre randomised trial

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