Influences of electrocardiographic ischemia grades and symptom duration on outcomes in patients with acute myocardial infarction treated with thrombolysis versus primary percutaneous coronary intervention (Results from the DANAMI-2 trial)

Maria Sejersten ^1*, Yochai Birnbaum ², Rasmus S. Ripa ³, Charles Maynard ⁴, Galen S Wagner ⁵ and Peter Clemmensen ¹

¹ Rigshospitalet, Copenhagen University Hospital, Denmark
² The University of Texas Medical Branch, United States
³ Rigshospitalet, Copenhagen University Hospital, East Timor
⁴ Department of Health Services, University of Washington, Seattle, WA, United States
⁵ DCRI, Duke University Medical Center, Durham, NC, United States

^* To whom correspondence should be addressed. E-mail: msejersten{at}webspeed.dk.

Accepted 17 May 2006

Abstract

Objective: Determine whether grades of ischemia (GI) on the presenting electrocardiogram and duration of symptoms can identify subgroups of patients in whom the advantage of primary percutaneous coronary intervention (pPCI) over thrombolytic therapy (TT) in reducing mortality and/or reinfarction is greater than in the general population of patients with ST elevation acute myocardium infarction (STEMI).

Methods: 1319 DANAMI-2 patients were classified as grade 2 (GI2, ST elevation without terminal QRS distortion) or grade 3 (GI3, ST elevation with terminal QRS distortion in ¡2 adjacent leads), and divided into early and late groups split by the median time (3h) from symptom onset to treatment. Outcomes were 30-day mortality and reinfarction.

Results: Mortality was significantly higher for GI3 versus GI2 (9.7% vs. 4.8%; p<0.001, and doubled for patients presenting late (GI2 6.0 vs. 3.3%, p=0.01; GI3 12.5% vs. 4.7%, p=0.05). Overall there was no significant difference in mortality between pPCI and TT; however, a 5.5% absolute mortality reduction was seen in GI3 treated early with pPCI (1.4% vs. 6.9%; p=0.10). Reinfarction rate was particularly high among GI3 patients presenting late and treated with TT (12.2%). pPCI in such patients significantly reduced the rate of reinfarction (0%; p<0.001). Logistic regression analysis showed that age (odds ratio (OR) 1.09; 95% CI 1.06-1.12; p<0.001), prior angina (OR 2.56; 95% CI 1.44-4.54; p=0.001), heart rate (OR 1.03; 95% CI 1.01-1.04; p=0.001), and GI3 (OR 1.91; 95% CI 1.06-3.44; p=0.031) were independently associated with mortality whereas the sum of ST elevation was not.

Conclusions: GI3 is an independent predictor of mortality among STEMI patients. Mortality increased significantly with symptom duration in both GI2 and GI3. pPCI may be especially beneficial for GI3 presenting early, while GI3 presenting late and treated with TT are at particular risk of reinfarction.

Keywords: fibrinolysis, ischemia grading system, outcome, primary percutaneous coronary intervention

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

This article has been cited by other articles:

• Eskola, M. J., Holmvang, L., Nikus, K. C., Sclarovsky, S., Tilsted, H.-H., Huhtala, H., Niemela, K. O., Clemmensen, P. (2007). The electrocardiographic window of opportunity to treat vs. the different evolving stages of ST-elevation myocardial infarction: correlation with therapeutic approach, coronary anatomy, and outcome in the DANAMI-2 trial. Eur Heart J 28: 2985-2991 [Abstract] [Full Text]  
• Kasapis, C., Nallamothu, B. K. (2007). Use of the electrocardiogram in optimizing reperfusion for ST-elevation myocardial infarction: a new role for an old tool?. Eur Heart J 28: 2957-2959 [Full Text]