(Circulation. 1998;98:1860-1868.)
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports |
Acute Coronary Syndromes in the GUSTO-IIb Trial
Prognostic Insights and Impact of Recurrent Ischemia
From the University of Alberta (P.W.A., Y.F., W.-C.C.), Edmonton, Alberta, Canada; the Cleveland Clinic Foundation (E.J.T.), Cleveland, Ohio; the Duke Clinical Research Institute (C.B.G., K.L.L., R.M.C.); Hospital Clinic (A.B.), University of Barcelona, Barcelona, Spain; and Universitaire Ziekenhuizen Leuven (F.V.d.W.), Leuven, Belgium.
Correspondence to Paul W. Armstrong, MD, Division of Cardiology, Department of Medicine, 2F1.30 W.C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada, T6G 2B7. E-mail paul.armstrong{at}ualberta.ca
Background—Recurrent ischemia after an acute coronary syndrome portends an unfavorable outcome and has major resource-use implications. This issue has not been studied systematically among the spectrum of patients with acute coronary presentations, encompassing those with and without ST-segment elevation.
Methods and Results—We assessed the 1-year prognosis of the 12 142 patients enrolled in the GUSTO-IIb trial by the presence (n=4125) or absence (n=8001) of ST-segment elevation. This latter group was further categorized into those with baseline myocardial infarction (n=3513) or unstable angina (n=4488). We also assessed the incidence of recurrent ischemia and its impact on outcomes. Recurrent ischemia was significantly rarer in those with ST-segment elevation (23%) than in those without (35%; P<0.001). Mortality at 30 days was greater among patients with ST-segment elevation (6.1% versus 3.8%; P<0.001) but less so at 6 months; by 1 year, mortality did not differ significantly (9.6% versus 8.8%). Patients with non–ST-segment-elevation infarction had higher rates of reinfarction at 6 months (9.8% versus 6.2%) and higher 6-month (8.8% versus 5.0%) and 1-year mortality rates (11.1% versus 7.0%) than such patients who had unstable angina.
Conclusions—Refractory ischemia was associated with an approximate doubling of mortality among patients with ST-segment elevation and a near tripling of risk among those without ST elevation. This study highlights not only the substantial increase in late mortality and reinfarction with non–ST-segment-elevation infarction but also the opportunities for better triage and application of therapeutic strategies for patients with recurrent ischemia.
Key Words: myocardial infarction • mortality • ischemia • prognosis
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