Which noninvasive risk assessment methods best predict mortality, reinfarction, and the need for revascularization in patients with acute myocardial infarction treated with thrombolysis?
Basic clinical information, exercise stress testing, and estimation of left ventricular function provide sufficient prognostic information in thrombolysed MI patients, with advanced noninvasive tests adding little value for low-to-medium risk subjects.
Abstract. Jensen‐Urstad M, Samad BA, Jensen‐Urstad K, Hulting J, Ruiz H, Bouvier F, Höjer J (Karolinska Hospital, Karolinska Institute, Stockholm; Söder Hospital, Karolinska Institute, Stockholm; Karolinska Hospital, Karolinska Institute, Stockholm; and Söder Hospital, Karolinska Institute, Stockholm, Sweden). Risk assessment in patients with acute myocardial infarction treated with thrombolytic therapy. J Intern Med 2001; 249 : 527–537. Objective. Several noninvasive methods have prognostic information regarding mortality and new coronary events after an acute myocardial infarction (AMI). The practical for clinical decision‐making in the immediate postmyocardial infarction (MI) period is, however, less evident. We investigated consecutive patients with AMI treated with thrombolysis to further clarify this issue. Design. A total of 100 patients (27% women) aged 64 ± 9 years (mean ± SD) were studied. Risk assessment based on a clinical score system, myocardial perfusion scintigraphy single photon emission computed tomography (SPECT) at rest and during adenosine stress, echocardiography, radionuclide angiography, symptom‐limited exercise stress test, and 24‐h Holter ECG recording with ST‐analysis and analysis of heart rate variability (HRV) were performed 5–8 days after hospital admission. Mortality, nonfatal reinfarction, and the need for revascularization were followed during 12 months. Setting. A university hospital. Results. A total of 6 patients died, seven had a nonfatal reinfarction, and 23 were revascularized. Inability to perform an exercise test ( P =0.004) and an ejection fraction (EF) <40% ( P =0.002) were the only parameters separating those who died from the survivors. No method could predict a nonfatal reinfarction. Patients suffering either death or nonfatal reinfarction had a clinical risk assessment score 2 points higher (8.8 vs. 6.7, P =0.05) than the group without such events. A positive symptom‐limited exercise stress test ( P =0.027), ST‐depressions on Holter ECG ( P =0.04), and reversibility on myocardial perfusion scintigraphy ( P =0.029) predicted the need for revascularization. Conclusion. Risk assessment based on clinical information, exercise stress testing, and an estimate of left ventricular function (e.g. via echocardiography) contribute with prognostic information in thrombolysed MI‐patients. Additional noninvasive investigations such as adenosine‐SPECT, analysis of HRV, and Holter‐monitoring do not add to these commonly available tools in risk stratification of subjects at low to medium risk.
Jensen‐Urstad et al. (2001) studied this question.