What is the clinical evidence from this study?

Study design: Cohort. Population: Silent ischemia after acute myocardial infarction (n=287). Intervention: ST depression >2 mm during stress test vs. ST elevation. Primary outcome: Combined cardiac endpoints (death, reinfarction, need for revascularization or admission with unstable angina) (RR 2.4, 95% CI 1.1-5.0).

What does this research mean for the field?

In patients with silent ischemia after a thrombolytic-treated first acute myocardial infarction, ST depression of >2 mm during a stress test significantly increases the risk of combined cardiac endpoints at 1 year compared to ST elevation. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

January 1, 2002

Exercise-Induced ST Depression as a Prognostic Indicator of Cardiac Morbidity in Thrombolytic-Treated Post-Myocardial Infarction Patients with Silent Ischemia

Key Result

ST depression of >2 mm during a stress test significantly increased the risk of combined cardiac endpoints compared to ST elevation at 1 year (RR 2.4; 95% CI 1.1-5.0).

Study Design

Type

Cohort (n=287)

Structured PICO

Does the degree of exercise-induced ST depression predict combined cardiac endpoints in patients with silent ischemia after a thrombolytic-treated first acute myocardial infarction?

Population

287 patients with silent postinfarct inducible ischemia (ST deviations during exercise without angina) after thrombolytic-treated first acute myocardial infarction, from the conservative treatment arm of the Danish Trial in Acute Myocardial Infarction.

Intervention

>2 mm of ST depression during a symptom-limited bicycle exercise stress test (Group C)

Comparator

ST elevation (Group A) or >1 to <2 mm of ST depression (Group B) during the stress test

Outcome

1-year incidence of combined cardiac endpoints (composite of death, reinfarction, need for revascularization, or admission with unstable angina)composite

In patients with silent ischemia after a thrombolytic-treated first acute MI, exercise-induced ST depression >2 mm is a significant prognostic indicator for increased 1-year cardiac morbidity.

Main Result

Effect estimate: RR 2.4 (95% CI 1.1-5.0)

Absolute Event Rate: 29% vs 15%

Abstract

Background: The significance of silent ischemia after acute myocardial infarction (MI) has been questioned. Objective: The aim of this study was to assess the risk for cardiac events in patients with silent ischemia after thrombolytic-treated first acute MI. Methods and Results: The Danish Trial in Acute Myocardial Infarction randomized 505 patients to conservative treatment after thrombolytic-treated first acute MI. For this analysis, patients were included if they demonstrated silent ischemia, i.e. ST deviations during exercise but without angina, during a symptom-limited bicycle exercise test. A total of 287 patients had silent postinfarct inducible ischemia. The 1-year incidence rate of combined cardiac endpoints, defined as death, reinfarction, need for revascularization or admission with unstable angina, was 22%. The level of maximum ST change during a stress test was used to categorize patients into three groups: group A: ST elevation (n = 54, 1-year event rate 15%); group B: >1 to 2 mm of ST depression during a stress test (n = 147, 1-year event rate 29%). Using a Cox proportional hazards model, the predictor of cardiovascular endpoints was the level of ST depression during a stress test (relative risk 2.4, 95% confidence limits 1.1–5.0, group C versus group A). Conclusion: This study identifies ST depression of more than 2 mm during a stress test as a significant risk factor for cardiac morbidity.

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