Clinical characteristics and long-term outcome of patients in whom congestive heart failure develops after thrombolytic therapy for acute myocardial infarction: Development of a predictive model,☆☆,

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Abstract

Ischemic heart disease is the most common cause of congestive heart failure, which often begins after acute myocardial infarction. To better delineate the clinical characteristics and outcomes of patients in whom congestive heart failure develops after acute myocardial infarction in the thrombolytic era, we prospectively evaluated patients enrolled in six of the TAMI trials. The study cohort comprised 1619 consecutive patients who had at least 1 mm of ST-segment elevation in two contiguous electrocardiographic leads within 6 hours of the onset of acute myocardial infarction and who received intravenous thrombolytic therapy. We prospectively collected clinical characteristics, baseline demographics, acute and 1-week angiographic variables, and in-hospital and 1-year outcome data. We performed stepwise multivariable regression analysis to determine the noninvasive and invasive predictors of the development of in-hospital congestive heart failure. Congestive heart failure developed in 301 patients in the hospital (19% of 1521 patients admitted were not in heart failure). These patients were likely to be older and female, have diabetes mellitus and previous myocardial infarction, and have an anterior wall myocardial infarction. On acute angiography, they had lower ejection fractions and a higher incidence of multivessel disease. Patency at 90 minutes was lower in the patients with congestive heart failure, and acute mitral regurgitation occurred in 1.6% versus 0.21% of patients without congestive heart failure. Patients with congestive heart failure had higher mortality, more in-hospital complications, and longer hospitalizations. At 1-year follow up, 21% of the patients in whom congestive heart failure developed had died versus 5% in the group without congestive heart failure. Predictors of new congestive heart failure included increased age, anterior wall myocardial infarction, lower pulse pressure and systolic blood pressure, diabetes mellitus, and the presence of rales on admission. The acute angiographic variables of reduced ejection fraction, increased number of diseased vessels, and attempted percutaneous intervention improved the concordance of the predictive model by 6%. Congestive heart failure remains a common clinical problem after acute myocardial infarction and is associated with a twofold increase in in-hospital morbidity and a fourfold increase in in-hospital and 1-year mortality. The development of congestive heart failure in the hospital can be predicted from noninvasive and invasive baseline characteristics. We present a simple table to predict congestive heart failure from baseline characteristics and invasive information. (Am Heart J 1997;133:663-73.)

Section snippets

Patients

The population for this study were the 1619 consecutive patients prospectively enrolled at seven regional cardiac centers and 29 community hospitals during the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) trials between December 1985 and June 1990. Patients were included in the study cohort if they were seen within 6 hours of the onset of symptoms compatible with acute myocardial infarction with >1 mm (0.1 mV) of ST-segment elevation in two or more leads on the

Baseline clinical characteristics and demographics

Among the 1619 patients enrolled in the six TAMI trials included in this study, 98 (6%) patients were admitted to the hospital with CHF and are excluded from further analysis in this article because of the primary objective of developing a model to predict new CHF. The incidence of CHF ranged from a low of 14% in the TAMI 5 study to a high of 28% in the TAMI 7 study. Patients in whom CHF developed after admission were older and more often female; they were more likely to be nonsmokers, with a

DISCUSSION

This study demonstrates that the prevalence of heart failure after myocardial infarction remains high despite the routine use of thrombolytic therapy, cardiac catheterization, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, and aggressive medical therapy. Once developed, CHF is associated with a high rate of short-term and long-term morbidity and mortality. Simple baseline and angiographic characteristics were used in our patient population to develop a simple

Acknowledgements

We thank all the members of the TAMI study group for their contributions over the past decade. We also thank Penny Hodgson for her editorial support. In addition, we thank Laverne Alston and Renee Story and Wendy Gattis for manuscript preparation.

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  • Cited by (0)

    Supported by research grants HS-05635 and HS-06503 from the Agency for Health Care Policy and Research, Rockville, Md., and grants from the Robert Wood Johnson Foundation, Princeton, N.J., and the DUCCS Research Foundation, Durham, N.C.

    ☆☆

    Reprint requests: Christopher M. O'Connor, MD, Box 3356, Duke University Medical Center, Durham, NC 27710.

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