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• W2034165048 abstract "Immediate management of patients with acute myocardial infarction currently includes therapies designed to reperfuse the occluded artery and surveillance for ventricular arrhythmias, pump failure, and mechanical complications. Subsequent decisions concern assessment for early and late risk of death, reinfarction, and need for intervention (angioplasty or bypass surgical procedures). Central to this process is the concept of risk stratification—the ability to identify patients with an increased risk of adverse outcomes in whom intervention will lower this risk. Although a wealth of data about such risk assessment exists for patients after a myocardial infarction, virtually all the information is derived from studies done during the prethrombolytic era. Much less information is available on risk stratification of patients who have undergone thrombolytic therapy, angioplasty, or some combination of the two. Herein we address two major questions: (1) Do the clinically derived “risk factors” for early death and reinfarction that have been established for patients who have not received thrombolysis apply to those who have? (2) What is the role of predismissal risk stratification for predicting late events in “thrombolytic era” patients? Prethrombolytic Era.— The “classic” (prethrombolytic) approach of early risk stratification is based on evidence that mortality after myocardial infarction relates to three factors: the amount of myocardial damage, residual myocardial ischemia, and electrical-autonomic instability. Additionally, three-vessel coronary disease in the setting of a decreased ejection fraction is a strong predictor of subsequent mortality (Table 1).1Sanz G Castaner A Betriu A Magrina J Roig E Coll S et al.Determinants of prognosis in survivors of myocardial infarction: a prospective clinical angiographic study.N Engl J Med. 1982; 306: 1065-1070Crossref PubMed Scopus (447) Google Scholar Typical historical, examination, and functional test variables and their associated odds ratio indicating increased early risk are shown in Table 2, as adapted by Krone2Krone RJ The role of risk stratification in the early management of a myocardial infarction.Ann Intern Med. 1992; 116: 223-237Crossref Scopus (47) Google Scholar from the multicenter postinfarction program. Features such as advanced age, diabetes mellitus, and other comorbidities are also known to cause increased risk. Severe left ventricular dysfunction, manifested as congestive heart failure or hypotension with hypoperfusion, indicates a poor prognosis with no identification of a correctable cause. The dire consequences of shock or development of a mechanical complication, such as rupture of a papillary muscle, are well known, especially if uncorrected. The prognosis of patients with an uncomplicated infarction is better than that for patients with a complication, although reports during the previous decade have demonstrated that predismissal exercise testing could help identify a subset of patients with increased risk of recurrent angina or death that would necessitate further treatment.3Theroux P Waters DD Halphen C Debaisieux J-C Mizgala HF Prognostic value of exercise testing soon after myocardial infarction.N Engl J Med. 1979; 301: 341-345Crossref PubMed Scopus (533) Google Scholar, 4Sami M Kraemer H DeBusk RF The prognostic significance of serial exercise testing after myocardial infarction.Circulation. 1979; 60: 1238-1246Crossref PubMed Scopus (126) Google Scholar, 5Starling MR Crawford MH Kennedy GT O'Rourke RA Exercise testing early after myocardial infarction: predictive value for subsequent unstable angina and death.AmJCardiol. 1980; 46: 909-914Abstract Full Text PDF Scopus (157) Google Scholar, 6Epstein SE Palmeri ST Patterson RE Evaluation of patients after acute myocardial infarction: indications for cardiac catheterization and surgical intervention.N EnglJ Med. 1982; 307: 1487-1492Crossref Scopus (113) Google Scholar, 7Waters DD Theroux P Halphen C Mizgala HF Clinical predictors of angina following myocardial infarction.Am J Med. 1979; 66: 991-996Abstract Full Text PDF PubMed Scopus (21) Google Scholar, 8Lindvall K Erhardt LR Lundman T Rehnqvist N Sjogren A Early mobilization and discharge of patients with acute myocardial infarction: a prospective study using risk indicators and early exercise tests.ActaMedScand. 1979; 206: 169-175Google Scholar, 9Granath A Sodermark T Winge T Volpe U Zetterquist S Early work load tests for evaluation of long-term prognosis of acute myocardial infarction.Br Heart J. 1977; 39: 758-765Crossref PubMed Scopus (68) Google Scholar, 10Markiewicz W Houston N DeBusk RF Exercise testing soon after myocardial infarction.Circulation. 1977; 56: 26-31Crossref PubMed Scopus (114) Google Scholar, 11Davidson DM DeBusk RF Prognostic value of a single exercise test 3 weeks after uncomplicated myocardial infarction.Circulation. 1980; 61: 236-242Crossref PubMed Scopus (139) Google Scholar, 12Koppes GM Kruyer W Beckmann CH Jones FG Response to exercise early after uncomplicated acute myocardial infarction in patients receiving no medication: long-term follow-up.Am J Cardiol. 1980; 46: 764-769Abstract Full Text PDF PubMed Scopus (53) Google Scholar, 13Madsen EB Rasmussen S Svendsen TL Multivariate long-term prognostic index from exercise ECG after acute myocardial infarction.EurJ Cardiol. 1980; 11: 435-443Google Scholar, 14Saunamaki KI Damgaard Andersen J Early exercise test in the assessment of long-term prognosis after acute myocardial infarction.Acta Med Scand. 1981; 209: 185-191Crossref PubMed Scopus (33) Google Scholar, 15Weld FM Chu KL Bigger Jr, JT Rolnitzky LM Risk stratification with low-level exercise testing 2 weeks after acute myocardial infarction.Circulation. 1981; 64: 306-314Crossref PubMed Scopus (165) Google Scholar, 16Fuller CM Raizner AE Verani MS Nahormek PA Chahine RA McEntee CW et al.Early post-myocardial infarction treadmill stress testing: an accurate predictor of multivessel coronary disease and subsequent cardiac events.Ann Intern Med. 1981; 94: 734-739Crossref PubMed Scopus (73) Google Scholar, 17Schwartz KM Turner JD Sheffield LT Roitman DI Kansal S Papapietro SE et al.Limited exercise testing soon after myocardial infarction: correlation with early coronary and left ventricular angiography.Ann Intern Med. 1981; 94: 727-734Crossref PubMed Scopus (77) Google Scholar Results of three often-quoted studies (Table 3) published around 1980 showed that patients with abnormal results on predismissal submaximal exercise tests had a mean 19% 1-year mortality rate in comparison with 2.6% for those with normal test results.3Theroux P Waters DD Halphen C Debaisieux J-C Mizgala HF Prognostic value of exercise testing soon after myocardial infarction.N Engl J Med. 1979; 301: 341-345Crossref PubMed Scopus (533) Google Scholar, 4Sami M Kraemer H DeBusk RF The prognostic significance of serial exercise testing after myocardial infarction.Circulation. 1979; 60: 1238-1246Crossref PubMed Scopus (126) Google Scholar, 5Starling MR Crawford MH Kennedy GT O'Rourke RA Exercise testing early after myocardial infarction: predictive value for subsequent unstable angina and death.AmJCardiol. 1980; 46: 909-914Abstract Full Text PDF Scopus (157) Google Scholar Subsequent studies have shown that the sensitivity of exercise testing in general can be increased by using symptom-limited testing to a higher workload18Juneau M Colles P Theroux P de Guise P Pelletier G Lam J et al.Symptom-limited versus low level exercise testing before hospital discharge after myocardial infarction.J Am Coll Cardiol. 1992; 20: 927-933Abstract Full Text PDF Scopus (59) Google Scholar or by using adjunctive radioisotope imaging, such as thallium,19Gibson RS Watson DD Craddock GB Crampton RS Kaiser DL Denny MJ et al.Prediction of cardiac events after uncomplicated myocardial infarction: a prospective study comparing predischarge exercise thallium-201 scintigraphy and coronary angiography.Circulation. 1983; 68: 321-336Crossref PubMed Scopus (442) Google Scholar with exercise, pharmacologic stress testing,20Leppo JA O'Brien J Rothendler JA Getchell JD Lee VW Dipyridamole-thallium-201 scintigraphy in the prediction of future cardiac events after acute myocardial infarction.NEngl J Med. 1984; 310: 1014-1018Crossref Scopus (265) Google Scholar or echocardiography.21Quinones MA Verani MS Haichin RM Mahmarian JJ Suarez J Zoghbi WA Exercise echocardiography versus 201T1 single-photon emission computed tomography in evaluation of coronary artery disease: analysis of 292 patients.Circulation. 1992; 85: 1026-1031Crossref PubMed Scopus (254) Google ScholarTable 1Major Determinants of Mortality After Myocardial Infarction Amount of myocardial necrosisResidual ischemiaElectrical instabilityThree-vessel coronary disease Open table in a new tab Table 2Features Associated With Increased Risk of Mortality in the Year After a Myocardial Infarction*Data from the multicenter postinfarction program obtained before use of reperfusion therapy.†ECG = electrocardiogram; SDNN = standard deviation of normal beat cycle lengths; VEB = ventricular ectopic beats.From Krone.2Krone RJ The role of risk stratification in the early management of a myocardial infarction.Ann Intern Med. 1992; 116: 223-237Crossref Scopus (47) Google Scholar By permission of the American College of Physicians.FeatureOdds ratio95% CI ‡95% confidence intervals were calculated by using Mantel-Haenszel estimates.Associated with amount of myocardial damage Symptom >1 mo2.21.3-3.6 Ejection fraction <40%4.22.3-7.6 Rales detected above lung bases7.64.4-12.9 Congestion on chest radiogram6.03.5-10.4 Previous myocardial infarction1.81.1-3.1Associated with residual ischemia Angina before dismissal1.30.76-2.2 Angina during exercise testing2.51.2-5.5Associated with electrical instabilityMore than 10 VEB/h2.71.4-1.5Abnormal signal-averaged ECG§Abnormal duration of low-amplitude signals >40 μV and root mean square voltage of the terminal 40 ms (P<0.001).8.0Associated with autonomic dysfunction Heart rate variability (SDNN <50 ms)3.82.2-6.3* Data from the multicenter postinfarction program obtained before use of reperfusion therapy.† ECG = electrocardiogram; SDNN = standard deviation of normal beat cycle lengths; VEB = ventricular ectopic beats.‡ 95% confidence intervals were calculated by using Mantel-Haenszel estimates.§ Abnormal duration of low-amplitude signals >40 μV and root mean square voltage of the terminal 40 ms (P<0.001). Open table in a new tab Table 3Ability of ST-Segment Depression on Exercise Testing to Predict Cardiac Death 1 Year After an Uncomplicated Myocardial Infarction*In patients without thrombolytic therapy.Adapted with permission from Epstein SE, Palmeri ST, Patterson RE. Evaluation of patients after acute myocardial infarction: indications for cardiac catheterization and surgical intervention. N Engl J Med 1982; 307:1487-1492, Table 1. Copyright 1982. Massachusetts Medical Society. All rights reserved.1-yr mortality (%)ReferenceNo. of patientsTotal≥1 mm ST-segment depressionNoST-segment depressionTheroux et al3Theroux P Waters DD Halphen C Debaisieux J-C Mizgala HF Prognostic value of exercise testing soon after myocardial infarction.N Engl J Med. 1979; 301: 341-345Crossref PubMed Scopus (533) Google Scholar2108.5251.0Sami et al4Sami M Kraemer H DeBusk RF The prognostic significance of serial exercise testing after myocardial infarction.Circulation. 1979; 60: 1238-1246Crossref PubMed Scopus (126) Google Scholar855.0220.0Starling et al5Starling MR Crawford MH Kennedy GT O'Rourke RA Exercise testing early after myocardial infarction: predictive value for subsequent unstable angina and death.AmJCardiol. 1980; 46: 909-914Abstract Full Text PDF Scopus (157) Google Scholar1308.0107.0Overall4257.5192.6* In patients without thrombolytic therapy. Open table in a new tab These studies of postinfarction risk assessment must be placed in the context of then-contemporary treatments. Most patients received no aspirin or β-blockade, therapies that have since been proved effective for secondary prevention of myocardial infarction and death.22ISIS-2 (Second International Study of Infarct Survival) Collaborative GroupRandomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2.Lancet. 1988; 2: 349-360PubMed Google Scholar, 23β-Blocker Heart Attack Study Group The β-Blocker Heart Attack Trial.JAMA. 1981; 246: 2073-2074Crossref PubMed Scopus (297) Google Scholar, 24Norwegian Multicenter Study Group Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction.NEngl J Med. 1981; 304: 801-807Crossref Scopus (1522) Google Scholar, 25β-Blocker Heart Attack Trial Research Group A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results.JAMA. 1982; 247: 1707-1714Crossref PubMed Scopus (1583) Google Scholar, 26International Collaborative Study GroupReduction of infarct size with the early use of timolol in acute myocardial infarction.N Engl J Med. 1984; 310: 9-15Crossref Scopus (196) Google Scholar In-hospital infarct mortality averaged 10 to 15%; an additional 10% of patients died within 1 year after dismissal, and left ventricular failure occurred in up to 30% of patients.6Epstein SE Palmeri ST Patterson RE Evaluation of patients after acute myocardial infarction: indications for cardiac catheterization and surgical intervention.N EnglJ Med. 1982; 307: 1487-1492Crossref Scopus (113) Google Scholar, 27Death rate among 795 patients in first year after myocardial infarction.JAMA. 1966; 197: 906-908Crossref Scopus (31) Google Scholar, 28Boyle JA Lorimer AR Early mobilisation after uncomplicated myocardial infarction: prospective study of 538 patients.Lancet. 1973; 2: 346-349Google Scholar, 29Moss AJ DeCamilla J Davis H Cardiac death in the first 6 months after myocardial infarction: potential for mortality reduction in the early posthospital period.AmJCardiol. 1977; 39: 816-820Abstract Full Text PDF Scopus (73) Google Scholar Recurrent events were noted to happen early, within 6 to 8 weeks after hospital dismissal. Intracoronary intervention and use of thrombolytic agents were not yet available. At angiography, the prevalence of left main stenosis and three-vessel disease was about 10% and 30 to 46%, respectively; severely abnormal ejection fraction (30% or less) occurred in up to 20% of cases.6Epstein SE Palmeri ST Patterson RE Evaluation of patients after acute myocardial infarction: indications for cardiac catheterization and surgical intervention.N EnglJ Med. 1982; 307: 1487-1492Crossref Scopus (113) Google Scholar, 30Betriu A Castaner A Sanz GA Pare JC Roig E Coll S et al.Angiographic findings 1 month after myocardial infarction: a prospective study of 259 survivors.Circulation. 1982; 65: 1099-1105Crossref PubMed Scopus (94) Google Scholar, 31Schulman SP Achuff SC Griffith LS Humphries JO Taylor GJ Mellits ED et al.Prognostic cardiac catheterization variables in survivors of acute myocardial infarction: a five year prospective study.J Am Coll Cardiol. 1988; 11: 1164-1172Abstract Full Text PDF PubMed Scopus (57) Google Scholar All these factors are known to be associated with a poor prognosis. In short, patients with acute myocardial infarction had a high prevalence of serious coronary disease and a substantial incidence of undesirable outcomes, a setting in which moderately accurate tests could be shown to have useful clinical predictive value. Even before the considerably decreased early and 1-year mortality rates of patients receiving thrombolytic therapy were reported, sophisticated analyses of “conventionally” treated patients raised the issue of the additive value of predismissal noninvasive risk stratification. A report from the Multicenter Postinfarction Research Group32Tibbits PA Evaul JE Goldstein RE Boccuzzi SJ Therneau TM Parker R et al.Serial acquisition of data to predict one-year mortality rate after acute myocardial infarction.Am J Cardiol. 1987; 60: 451-455Abstract Full Text PDF PubMed Scopus (26) Google Scholar used logistic regression and receiver-operator33Swets JA Pickett RM Evaluation of Diagnostic Systems: Methods From Signal Detection Theory. Academic Press, New York1982: 3Google Scholar characteristic analyses to determine predictors of 1-year prognosis in 866 patients with acute myocardial infarction. After consideration of clinical variables such as rales, left bundle branch block, and symptom status 1 month before admission, only resting radionuclide ejection fraction provided additional prognostic information. No other radionuclide variable nor any exercise test variable achieved clinical significance; however, perfusion imaging was not used. Other studies34Bleich SD Nichols TC Schumacher RR Cooke DH Tate DA Teichman SL Effect of heparin on coronary arterial patency after thrombolysis with tissue plasminogen activator in acute myocardial infarction.AmJCardiol. 1990; 66: 1412-1417Abstract Full Text PDF Scopus (234) Google Scholar, 35Mickley H Pless P Nielsen JR Berning J Moller M Transient myocardial ischemia after a first acute myocardial infarction and its relation to clinical characteristics, predischarge exercise testing and cardiac events at one-year follow-up.AmJCardiol. 1993; 71: 139-144Abstract Full Text PDF Scopus (27) Google Scholar, 36Fubini A Cecchi E Bobbio M Spinnler MT Bergerone S Di Leo M et al.Value of exercise stress test, radionuclide angiography and coronary angiography in predicting new coronary events in asymptomatic patients after a first episode of myocardial infarction.Int J Cardiol. 1992; 34: 319-325Abstract Full Text PDF Scopus (10) Google Scholar performed predominantly in patients who did not undergo thrombolysis have shown a somewhat lower predictive accuracy of exercise testing even when associated with thallium perfusion imaging or technetium blood pool imaging. The largest study, by Moss and associates,37Moss AJ Goldstein RE Hall WJ Bigger Jr, JT Fleiss JL Greenberg H for the Multicenter Myocardial Ischemia Research Group et al.Detection and significance of myocardial ischemia in stable patients after recovery from an acute coronary event.JAMA. 1993; 269: 2379-2385Crossref Scopus (120) Google Scholar of 936 patients demonstrated that the only noninvasive test variable to identify a significantly increased risk was resting ST-segment depression. Although prespecified analysis showed that the combination of exercise ST-segment depression and exercise duration of less than 9 minutes identified patients with an increased risk of subsequent events, such patients constituted only 5% of the total cohort with late events; the other 95% of events were unidentified by these criteria. This study has important limitations, as subsequently discussed. In a study by Birk Madsen and colleagues38Birk Madsen E Gilpin E Ahnve S Henning H Ross Jr, J Prediction of functional capacity and use of exercise testing for predicting risk after acute myocardial infarction.Am J Cardiol. 1985; 56: 839-845Abstract Full Text PDF Scopus (41) Google Scholar of 466 patients who underwent predismissal exercise testing, resting but not exercise ST-segment depression correlated with functional capacity; exercise capacity was the only multivariate predictor of subsequent mortality. Patients able to exercise 4 or more mets (metabolic energy equivalents) had a 2% subsequent incidence of death or myocardial infarction within 1 year in comparison with 18% for those with lower functional capacity. A thorough examination of these studies demonstrates the important effects of selection bias on outcome. In the Multicenter Postinfarction Research Group study,32Tibbits PA Evaul JE Goldstein RE Boccuzzi SJ Therneau TM Parker R et al.Serial acquisition of data to predict one-year mortality rate after acute myocardial infarction.Am J Cardiol. 1987; 60: 451-455Abstract Full Text PDF PubMed Scopus (26) Google Scholar exercise testing was performed in 77% of postinfarct patients in comparison with 32% in the Birk Madsen study,38Birk Madsen E Gilpin E Ahnve S Henning H Ross Jr, J Prediction of functional capacity and use of exercise testing for predicting risk after acute myocardial infarction.Am J Cardiol. 1985; 56: 839-845Abstract Full Text PDF Scopus (41) Google Scholar a more than twofold difference and an indication of substantially different patient populations or practice patterns (or both). A consistent finding of all studies that report outcome of untested patients is a substantially higher mortality in those not selected for exercise testing; thus, patients undergoing predismissal testing are a select low-risk group. Finally, recent trends for an aggressive predismissal intervention in patients considered clinically at high risk yield a low-risk subpopulation as candidates for predismissal testing. This situation is perhaps best demonstrated in the study by Moss and coworkers,37Moss AJ Goldstein RE Hall WJ Bigger Jr, JT Fleiss JL Greenberg H for the Multicenter Myocardial Ischemia Research Group et al.Detection and significance of myocardial ischemia in stable patients after recovery from an acute coronary event.JAMA. 1993; 269: 2379-2385Crossref Scopus (120) Google Scholar in which 37% of the potential study candidates were excluded because of early postinfarction revascularization, major comorbidity, or inability to exercise.39Diamond GA Postinfarction risk stratification: is preventive war winnable?.JAMA. 1993; 269: 2418-2419Crossref Scopus (7) Google Scholar Thrombolytic Era.— The advent of thrombolytic therapy for acute myocardial infarction resulted in substantially lower morbidity and mortality rates for patients who received such therapy (and control subjects) in comparison with noncandidates. In the Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI) trial40Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI) Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction.Lancet. 1986; 1: 397-401PubMed Google Scholar and the Second International Study of Infarct Survival (ISIS-2)22ISIS-2 (Second International Study of Infarct Survival) Collaborative GroupRandomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2.Lancet. 1988; 2: 349-360PubMed Google Scholar of streptokinase versus placebo, mortality for the control group averaged 12 to 13%, and for the thrombolytic group, 8 to 10%. Patients considered noncandidates for thrombolysis have had mortality rates of 15 to 20% or more.41Cragg DR Friedman HZ Bonema JD Jaiyesimi IA Ramos RG Timmis GC et al.Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy.Ann Intern Med. 1991; 115: 173-177Crossref PubMed Scopus (182) Google Scholar Recently, the Global Utilization of Streptokinase and Tissue Plasminogen Activator to Treat Occluded Arteries (GUSTO) trial,42GUSTO Investigators An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.N Engl JMed. 1993; 329: 673-682Crossref Scopus (3672) Google Scholar a comparison of streptokinase and tissue-type plasminogen activator, reported a 35-day mortality rate of 6.3 to 7.3%. More important, long-term mortality after thrombolysis has been extremely low. In the Thrombolysis in Myocardial Infarction Phase II (TIMI II) trial43Williams DO Braunwald E Knatterud G Babb J Bresnahan J Greenberg MA et al.One-year results of the Thrombolysis in Myocardial Infarction (TIMI) phase II trial.Circulation. 1992; 85: 533-542Crossref PubMed Scopus (113) Google Scholar that compared aggressive versus conservative revascularization approaches after thrombolysis, the mortality rate during the year after hospital dismissal ranged from 2.0 to 3.3%. In the SWIFT (Should We Intervene Following Thrombolysis?) trial,44SWIFT (Should We Intervene Following Thrombolysis?) Trial Study Group SWIFT trial of delayed elective intervention v conservative treatment after thrombolysis with anistreplase in acute myocardial infarction.BMJ. 1991; 302: 555-560Crossref PubMed Google Scholar the 1-year mortality rate ranged from 2.5 to 3.3%. In the TIMI II trial, 2- and 3-year subsequent mortality rates were 1.3% and 1.7%, respectively.45Terrin ML Williams DO Kleiman NS Willerson J Mueller HS Desvigne-Nickens P et al.Two- and three-year results of the Thrombolysis in Myocardial Infarction (TIMI) Phase II clinical trial.J Am Coll Cardiol. 1993; 22: 1763-1772Abstract Full Text PDF PubMed Scopus (64) Google Scholar Because of considerably lower initial and subsequent mortality rates, one might question whether any of the risk factors established in the prethrombolytic era are currently applicable. Additionally, the very low 1- year subsequent mortality in the TIMI II and SWIFT trials might be expected to decrease substantially the predictive accuracy of noninvasive risk stratification based on the Bayes theorem. The lower infarct mortality noted in patients who have received thrombolytic therapy is likely multifactorial. The selection effect is important, inasmuch as candidates for thrombolytic therapy represent a special population with low comorbidities and less advanced coronary disease. In recent trials with angiographic arms, the proportion of patients with three-vessel disease has been low (5 to 11%)46Rogers WJ Babb JD Bairn DS Chesebro JH Gore JM Roberts R for the TIMI II Investigators et al.Selective versus routine predischarge coronary arteriography after therapy with recombinant tissue-type plasminogen activator, heparin and aspirin for acute myocardial infarction.J Am Coll Cardiol. 1991; 17: 1007-1016Abstract Full Text PDF PubMed Scopus (36) Google Scholar(Fig. 1), and average ejection fractions have been almost 50%.49TIMI Study Group Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) Phase II Trial.NEngl J Med. 1989; 320: 618-627Crossref Scopus (1052) Google Scholar Substantial numbers of high-risk patients (those with recurrent chest pain and electrocardiographic [ECG] changes during hospitalization) generally undergo prompt revascularization by angioplasty or an operation; thus, a low-risk group of “uncomplicated” patients who have not had intervention at dismissal are selected for study. Thus, patient selection is a major confounding risk factor for prediction by noninvasive testing early after a myocardial infarction (Fig. 2).50Lavie CJ Gibbons RJ Zinsmeister AR Gersh BJ Interpreting results of exercise studies after acute myocardial infarction altered by thrombolytic therapy, coronary angioplasty or bypass.Am J Cardiol. 1991; 67: 116-120Abstract Full Text PDF Scopus (21) Google ScholarFig. 2Patient selection effects in risk stratification studies in thrombolytic era. * = high-risk patients excluded before noninvasive testing—selection effects that render noninvasive testing less useful for predicting death or myocardial infarction (MI) in current era of thrombolytic therapy. PTCA = percutaneous transluminal coronary angioplasty.View Large Image Figure ViewerDownload (PPT) One might logically ask whether the low late mortality rates in the TIMI II trial are, in fact, related to intervention provided (that is, revascularization) on the basis of abnormal predismissal test results. This relationship seems unlikely when the TIMI II data are analyzed thoroughly. In the conservative strategy group in whom selective catheterization and revascularization were performed for verified ischemia, an abnormal predismissal exercise test result was the reason for catheterization in only 2% of cases.46Rogers WJ Babb JD Bairn DS Chesebro JH Gore JM Roberts R for the TIMI II Investigators et al.Selective versus routine predischarge coronary arteriography after therapy with recombinant tissue-type plasminogen activator, heparin and aspirin for acute myocardial infarction.J Am Coll Cardiol. 1991; 17: 1007-1016Abstract Full Text PDF PubMed Scopus (36) Google Scholar Indeed, spontaneous postinfarct ischemia was 10 times more common than exercise-induced ischemia as a reason for intervention. Whether early intervention by percutaneous transluminal coronary angioplasty or bypass is related to low late mortality is questionable. In the TIMI II study, 20.7% of patients underwent early (within 3 weeks) revascularization, whereas in the SWIFT study, approximately 5% did; at 1&x2013;year follow-up, cumulative revascularization rates were 35.5% and 15%, respectively. Despite the substantially higher rate of revascularization in the TIMI II trial, almost identical survival rates were demonstrated in both trials during the year after dismissal. The best evidence that traditional clinical predictors of early postinfarction risk remain valid in the thrombolytic era is derived from the TIMI II trial. With use of prespecified clinical variables, a “low-risk” and “not low-risk” (Table 4) classification was made at the time of randomization. At 42-day follow-up, the mortality rate was 1.4% in the lowrisk group versus 5% in the not low-risk group. Mortality increased dramatically with increasing numbers of risk factors, up to 17.2% with 4 or more present (Fig. 3).51Hillis LD Forman S Braunwald E Thrombolysis in Myocardial Infarction (TIMI) Phase II Co-investigators Risk stratification before thrombolytic therapy in patients with acute myocardial infarction.J A" @default.
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• W2034165048 title "Acute Myocardial Infarction: Risk Stratification in the Thrombolytic Era" @default.
• W2034165048 cites W1515026043 @default.
• W2034165048 cites W1548990295 @default.
• W2034165048 cites W1595061751 @default.
• W2034165048 cites W1596397105 @default.
• W2034165048 cites W1970169412 @default.
• W2034165048 cites W1975935837 @default.
• W2034165048 cites W1984943566 @default.
• W2034165048 cites W1985177680 @default.
• W2034165048 cites W1986473830 @default.
• W2034165048 cites W1988109523 @default.
• W2034165048 cites W1990730383 @default.
• W2034165048 cites W1990976182 @default.
• W2034165048 cites W1993995794 @default.
• W2034165048 cites W1994392464 @default.
• W2034165048 cites W1999080316 @default.
• W2034165048 cites W2001073440 @default.
• W2034165048 cites W2003981818 @default.
• W2034165048 cites W2004975764 @default.
• W2034165048 cites W2006831346 @default.
• W2034165048 cites W2007403063 @default.
• W2034165048 cites W2008472820 @default.
• W2034165048 cites W2014258384 @default.
• W2034165048 cites W2017023279 @default.
• W2034165048 cites W2021716008 @default.
• W2034165048 cites W2022298481 @default.
• W2034165048 cites W2026792416 @default.
• W2034165048 cites W2026820511 @default.
• W2034165048 cites W2027451119 @default.
• W2034165048 cites W2036565320 @default.
• W2034165048 cites W2046352917 @default.
• W2034165048 cites W2048391482 @default.
• W2034165048 cites W2049373023 @default.
• W2034165048 cites W2050426293 @default.
• W2034165048 cites W2051522342 @default.
• W2034165048 cites W2051989575 @default.
• W2034165048 cites W2052601352 @default.
• W2034165048 cites W2054497842 @default.
• W2034165048 cites W2055464846 @default.
• W2034165048 cites W2055667043 @default.
• W2034165048 cites W2060932941 @default.
• W2034165048 cites W2061123572 @default.
• W2034165048 cites W2066307634 @default.
• W2034165048 cites W2069600595 @default.
• W2034165048 cites W2072670056 @default.
• W2034165048 cites W2073748321 @default.
• W2034165048 cites W2073786277 @default.
• W2034165048 cites W2075476190 @default.
• W2034165048 cites W2080509779 @default.
• W2034165048 cites W2088958446 @default.
• W2034165048 cites W2091724788 @default.
• W2034165048 cites W2095500449 @default.
• W2034165048 cites W2116240602 @default.
• W2034165048 cites W2164771213 @default.
• W2034165048 cites W2210661366 @default.
• W2034165048 cites W2268325176 @default.
• W2034165048 cites W2312388685 @default.
• W2034165048 cites W2314885057 @default.
• W2034165048 cites W2319647857 @default.
• W2034165048 cites W2325294960 @default.
• W2034165048 cites W2333920681 @default.
• W2034165048 cites W2337272710 @default.
• W2034165048 cites W2338398701 @default.
• W2034165048 cites W2340399630 @default.
• W2034165048 cites W2412010777 @default.
• W2034165048 cites W2414473004 @default.
• W2034165048 cites W2416484142 @default.
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