Article Text
Abstract
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); χ2 = 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.
- mortality
- revascularisation
- acute coronary syndrome
- 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