Published Online
on September 8, 2008

A more recent version of this article appeared on September 23, 2008

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Submitted on January 18, 2008
Accepted on July 15, 2008

ST-Segment Recovery and Outcome After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. Insights From the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) Trial

Christopher E. Buller MD, Yuling Fu MD, Kenneth W. Mahaffey MD, Thomas G. Todaro MD, Peter Adams MD, Cynthia M. Westerhout PhD, Harvey D. White MD, Arnoud W.J. van't Hof MD, Frans J. Van de Werf MD, Galen S. Wagner MD, Christopher B. Granger MD, and Paul W. Armstrong MD^*

From Vancouver General Hospital (C.E.B.), University of British Columbia, Vancouver, British Columbia, Canada; University of Alberta (Y.F., C.M.W., P.W.A.), Edmonton, Alberta, Canada; Duke Clinical Research Institute (K.W.M., G.S.W., C.B.G.), Durham, NC; Procter & Gamble (T.G.T.), Cincinnati, Ohio; Alexion Pharmaceuticals (P.A.), Cheshire, Conn; Green Lane Cardiovascular Research Unit (H.D.W.), Auckland, New Zealand; Isala Klinieken (A.W.J.v.H.), Zwolle, Netherlands; and University Hospital Gasthuisberg (F.J.V.d.W.), Leuven, Belgium.

^* To whom correspondence should be addressed. E-mail: paul.armstrong{at}ualberta.ca.

Background—Primary percutaneous coronary angioplasty is an effective and widely adopted treatment for acute myocardial infarction. A simple method of determining prognosis after primary percutaneous coronary intervention (PCI) would facilitate appropriate care and expedite hospital discharge. Thus, we determined the prognostic importance of various measures of ST-segment–elevation recovery after primary PCI in a large, contemporary cohort of patients with ST-elevation myocardial infarction.

Methods and Results—We analyzed ECG data describing the magnitude and extent of ST-segment elevation and deviation before and early after (ie, 30 minutes) primary PCI in the study cohort of 4866 subjects with electrocardiographically high-risk ST-elevation myocardial infarction enrolled in the Assessment of PEXelizumab in Acute Myocardial Infarction (APEX-AMI) trial. Associations among 6 methods for calculating ST-segment recovery, biomarker estimates of infarct size (ie, peak creatine kinase, creatine kinase-MB, and troponin I and T), and prespecified clinical outcomes (ie, rates of 90-day death and 90-day death, heart failure, or shock) were examined. All ST-segment–recovery methods provided strong prognostic information regarding clinical outcomes. A simple ST-segment–recovery method of residual ST-segment elevation measurement in the most affected lead on the post-PCI ECG performed as well as complex methods that required comparison of pre- and post-PCI ECGs or calculation of summed ST-segment deviation in multiple leads (ie, worst-lead residual ST elevation: adjusted hazard ratio for 90-day death rate [reference <1 mm]: 1 to <2 mm, 1.23 [95% CI 0.74 to 2.03]; 2 mm, 2.22 [95% CI 1.35 to 3.65], corrected c-index=0.832; 90-day death/congestive heart failure/shock [reference <1 mm]: 1 to <2 mm, 1.55 [95% CI 1.06 to 2.26]; 2 mm, 2.33 [95% CI 1.59 to 3.41], corrected c-index=0.802). Biomarker estimates of infarct size declined in association with enhanced ST-segment recovery.

Conclusions—An ECG performed early after primary PCI is a simple, widely available, inexpensive, and powerful prognostic tool applicable to patients with ST-elevation myocardial infarction.

Key words: angioplasty • electrocardiography • infarction • prognosis

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