空腹血糖是急性心肌梗死30天死亡率重要的独立危险因素

急性心肌梗死(AMI)病人应激性高血糖与死亡率增加密切相关,该文采用前瞻性研究比较AMI病人空腹血糖(FG)和入院时血糖(AG)对AMI病人30天死亡率的预测价值. 方法2001年6月至2004年1月,入选Ramban心脏中心的AMI病人,无糖尿病735例,有糖尿病310例,分别测定AG和FG(平均距入院14.7h).按FG水平分组,正常FG(<110     

糖化血红蛋白浓度对急性心肌梗死患者心力衰竭的预测价值

目的研究糖化血红蛋白(HbA1c)浓度、入院血糖(AG)及第2日清晨空腹血糖(FBG)对急性心肌梗死(AMI)患者30d时发生心力衰竭(HF)的预测价值。方法测定AMI患者HbA1c、AG及FBG值。根据AMI患者发病30d时有无HF分为两组,观察上述指标与HF的关系。结果145例AMI患者的HbA1c(P=0.041)和FBG(P=0.043)与30d发生HF相关,且HbA1c(P=0.016)为AMI 30 d HF发生的独立危险因子。结论高血糖能预测AMI近期发生HF。HbA1c是AMI短期HF发生的独立危险因子。     

肾小球滤过率对老年急性心肌梗死近期预后的影响

目的探讨入院时估测肾小球滤过率(eGFR)对老年急性心肌梗死(AMI)住院患者近期(30d内)预后的影响。方法入选2001年1月至2007年12月因AMI收住的327例老年患者为研究对象。根据入院时eGFR水平ml/(min·1.73m2)分为4组:肾功能正常组(eGFR≥80),轻度肾功能不全组(eGFR60～79),中度肾功能不全组(eGFR30～59)及重度肾功能不全组(eGFR30)。统计分析30d心源性病死和心脏并发症(心源性休克、心力衰竭或室速/室颤)的发生率及影响近期预后的相关因素。结果 4组患者30d病死率分别为3.7%、12.1%、23.6%和28.6%,心脏并发症的发生率分别为15.4%、37.4%、59.7%和64.3%(均P0.01)。单因素分析显示,年龄,糖尿病、脑卒中病史,贫血,首发症状呼吸困难,并发心源性休克、心力衰竭或室速/室颤及入院时eGFR减低是30d病死率的危险因素(均P0.05)。多因素分析显示,入院时eGFR减低、年龄、伴糖尿病者30d病死率均增高,比值比(OR)分别为1.6095%可信区间(CI)1.08～2.36、1.07(95%CI1.02～1.13)和3.34(95%CI1.34～8.34);住院期间发生心源性休克、心力衰竭及室速/室颤者同样也增加30d病死率,OR分别为16.18(95%CI4.68～55.97)、5.33(95%CI2.26～12.56)和3.99(95%CI1.29～12.33)。结论老年AMI患者入院时eGFR降低是急性期预后的独立预测因子。     

入院血糖水平对ST抬高急性心肌梗死预后的影响

目的 探讨入院时血糖水平对ST段抬高急性心肌梗死(STEMI)患者30 d死亡和主要心血管不良事件(MACE)发生率的预测价值.方法 对7446例12 h内STEMI患者以入院时不旧的血糖水平和有否糖尿病史分成4组(高血糖定为入院血糖>10 mmol/L),Ⅰ组:无糖尿病史且血糖正常组(对照组);Ⅱ组:有糖尿病史但血糖正常组;Ⅲ组:无糖尿病史但高血糖组;Ⅳ组:有糖尿病史且高血糖组.结果 入院高血糖两组患者30 d病死率和MACE的发生率明显高于对照组(病死率Ⅰ组8.6%比Ⅲ组17.1%、组Ⅳ18.6%;MACE Ⅰ组21.6%比Ⅲ组36.3%、Ⅳ组38.8%;P值均<0.001).Ⅱ组与对照组相比,30 d病死率没有明显增加(11.6%比8.6%,P=0.096).多因素回归分析显示Ⅲ、Ⅳ组的死亡危险分别为Ⅰ组患者的1.51倍(P<0.001)和1.83倍(P<0.1301);入院血糖水平是30 d死亡的独立危险因素,血糖水平每升高1 mmol/L,病死率增加5%(OR 1.05,95%CI1.04～1.07,P<0.001),而糖尿病史对30 d病死率不具有独立预测价值(OR 1.11,95%CI 0.87～1.42,P=0.412).结论 入院高血糖STEMI患者30 d病死率和MACE的发生率显著高于入院血糖正常者,入院高血糖为近期预后不良的独立危险因素,糖尿病史与近期病死率并无明显相关性.     

血糖控制状态对急性ST段抬高型心肌梗死行经皮冠状动脉介入治疗的糖尿病患者预后的影响

目的评估入院随机血糖及糖化血红蛋白(HbA1c)水平对急性ST段抬高型心肌梗死(STEMI)行经皮冠状动脉介入治疗(PCI)的糖尿病患者长期预后的影响。方法本次研究为回顾性研究,纳入176例因STEMI入住宣武医院行PCI的糖尿病患者,根据其入院随机血糖及HbA1c水平将患者分为2组,分别为血糖控制良好组(入院随机血糖<10 mmol/L,并且入院HbA1c<7%)和血糖控制欠佳组(入院随机血糖≥10 mmol/L,或入院HbA1c≥7%),比较两组患者出院后24个月内全因死亡及主要不良心脑血管事件(MACCEs,包括心原性死亡、支架内血栓形成、再次血运重建、心肌梗死和脑卒中)。结果 176例患者中,与血糖控制良好组相比,血糖控制欠佳组患者的入院血糖、入院HbA1c、三酰甘油及载脂蛋白B水平均明显升高(均为P<0.05)。随访24个月,与血糖控制良好组相比,血糖控制欠佳组患者的全因死亡率(18.8%比7.8%,P=0.048)、心原性死亡率(18.8%比3.1%,P=0.004)及MACCEs发生率(25.0%比10.9%,P=0.025)明显升高。入院Killip分级≥Ⅱ级(HR=4.302, 95%CI:1.505～12.295,P=0.006)和三酰甘油升高(HR=1.035, 95%CI:1.013～1.057,P=0.002)是24个月内全因死亡的危险因素,入院HbA1c升高(HR:1.229, 95%CI:1.003～1.508,P=0.047)、Killip分级≥Ⅱ级(HR=3.505, 95%CI:1.424～8.624,P=0.006)、脑卒中史(HR=3.525, 95%CI:1.361～9.129,P=0.009)及冠心病史(HR=2.886, 95%CI:1.078～7.724,P=0.035)则是24个月内MACCEs发生的危险因素。结论良好的血糖控制状态将有助于降低合并STEMI的糖尿病患者不良心脑血管事件的发生率,并改善其长期预后。     

入院24 h平均血糖对急性ST段抬高型心肌梗死患者近期预后的影响

目的 探讨人院24 h平均血糖(mean blood glucose,MBG)与急性ST段抬高型心肌梗死(STEMI)患者近期病死率及不良心血管事件的相关性.比较MBG与入院血糖(admission glucose,AG)对顶后影响的顶测价值.方法 人选病例来自2001至2004年间我国274家中心参加CREATE(Clinical trial of reviparin and metabolic modulation in acute myocardial infarction treatment evaluation)研究数据库、症状出现12 h内STEMI的中国患者7446例,将入院即刻、6 h、24 h血糖值计箅均值,以入院第1个24 h的MBG水平分成6组,即MBG＜4.5 mmol/L组、4.5～5.5 mmol/L组、5.6～7.0 mmol/L组、7.1～8.5 mmol/L组、8.6～11.0 mmol/L组和MBG＞11.0 mmol/L组.以MBG 4.5～5.5 mmol/L组作为对照组,其他血糖水平组与之进行比较.分析7 d和30 d病死率及联合终点事件发生情况.比较MBG与AG对上述事件预测价值的影响.结果 单因素分析显示,7 d、30 d病死率、联合终点事件发生率随着MBG水平升高而逐渐升高.MBG 7.1～8.5 mmol/L及以上组与MBG 4.5～5.5 mmol/L组的患者比较,差异均有统计学意义.多因素logistic回归分析显示MBG 7.1～8.5 mmol/L及以上各组是STEMI患者7 d、30 d病死率、联合终点事件的独立危险因素.MBG 7.1～8.5 mmol/L、8.6～11.0 mmol/L和＞11.0 mmol/L的患者7 d死亡危险分别比对照组患者增加56%(P=0.022)、61%(P=0.018)和230%(P＜0.001),30 d死亡危险分别比对照组患者增加41%(P=0.048)、40%(P=0.032)和185%(P＜0.001).MBG＜4.5 mmol/L组30 d联合终点事件发生危险无明显增加(P=0.085).应用Nested模型对AG及24 h MBG对病死率以及联合终点事件预测模型比较显示,24 hMBG较AG预测价值更大(均P＜0.001).结论 24 h MBG≥7.1 mmol/L与STEMI患者7 d、30 d病死率增高相关.24 h MBG较AG对预后具有更好的预测价值.     

老年急性冠状动脉综合征患者预后危险因素分析

目的 探讨急性冠状动脉综合征(ACS)患者的近期预后与影响临床预后的危险因素,为ACS患者的预后风险评估提供依据.方法 入选ACS患者156例.采用无序多分类Logistic回归分析ACS患者的基线特征因素与30 d好转、死亡、心绞痛、心力衰竭的相关性.结果 将全部变量进行多因素Logistic回归分析,显示年龄(OR=1.20,95%CI:1.07～1.34)、糖尿病(OR=19.41,95%CI:3.02～124.70)、白细胞升高(OR=11.36,95%CI:1.87～69.11)及血小板升高(OR=7.72,95%CI:1.29～46.15)是30 d死亡的独立危险因素;白细胞升高(OR=2.35,95%CI:0.89～6.17)及血脂异常(OR=6.25,95%CI:2.11～18.48)是30 d心绞痛发作的独立危险因素;年龄(OR=1.10,95%CI:1.03～1.17)、男性(OR=4.18,95%CI:0.81～21.51)、白细胞升高(OR=2.97,95%CI:1.09～8.14)及血脂异常(OR=7.69,95%CI:2.39～24.76)是30 d发生心力衰竭的独立危险因素.结论 年龄、糖尿病史、血小板升高及白细胞升高是影响ACS患者30 d死亡的独立危险因素;白细胞升高及血脂异常是影响ACS患者30 d心绞痛发作的独立危险因素;年龄、男性、白细胞升高及血脂异常是影响ACS患者30 d心力衰竭的独立危险因素.

Abstract：

Objective To explore short-term prognosis of patients with acute coronary syndrome (ACS) and prognostic risk factors, and to provide information for prognostic risk assessment. Methods A total of 156 patients with acute coronary syndrome were enrolled. The correlations of baseline characteristics with 30-day improvement, death, angina pectoris and heart failure were analyzed using unordered multivariate logistic regression. Results Logistic regression analysis showed that the independent risk factors for 30-day death included age (OR=1.20, 95%CI: 1.07-1.34), diabetes (OR=19.41, 95%CI: 3.02-124.70), leukocytosis (OR=11.36, 95%CI: 1.87-69.11) and increased platelet (OR=7.72, 95%CI: 1.29-46.15). The independent risk factors for 30-day angina pectoris included leukocytosis (OR=2.35, 95%CI: 0.89-6.17) and dyslipidemia (OR=6.25, 95%CI: 2.11-18.48). The independent risk factors for the occurrence of heart failure during 30-day post-ACS included age (OR=1.10, 95%CI: 1.03-1.17), male (OR=4.18, 95%CI: 0.81-21.51), leukocytosis (OR=2.97, 95%CI: 1.09-8.14) and dyslipidemia (OR=7.69, 95%CI: 2.39-24.76). Conclusions Age, diabetes, leukocytosis and increased platelet are independent risk factors associated with 30-day death; Leukocytosis and dyslipidemia are independent risk factors associated with 30-day angina pectoris; Age, male, leukocytosis and dyslipidemia are the independent risk factors associated with 30-day heart failure.     

052 空腹血糖是急性心肌梗死30天死亡率重要的独立危险因素[英]

急性心肌梗死（AMI）病人应激性高血糖与死亡率增加密切相关，该文采用前瞻性研究比较AMI病人空腹血糖（FG）和入院时血糖（AG）对AMI病人30天死亡率的预测价值。     

高敏C-反应蛋白对经皮冠状动脉介入术后对比剂肾病风险预测价值

目的:探讨经皮冠状动脉介入治疗术前高敏C反应蛋白(hs-CRP)水平与患者术后对比剂急性肾损伤(CI-AKI)的发生率及远期预后的关系。方法:连续入选1 820例于我院行择期经皮冠状动脉介入治疗患者,排除急性心肌梗死、近期手术或创伤的患者。根据术前hs-CRP值分为3组:hs-CRP升高组(hs-CRP>3 mg/L,n=546)、hs-CRP轻度升高组(hs-CRP 1～3 mg/L,n=650)和hs-CRP正常组(hs-CRP<1 mg/L,n=624)。结果:中位随访时间为26个月。与hs-CRP正常组相比,hs-CRP升高组术后CI-AKI发生率显著增加(10.9%vs.14.8%vs.23.1%,P<0.0001)。经过Logistic回归校正临床基线资料后,术前hs-CRP水平仍然是对比剂急性肾损伤发生率的独立预测因素。此外,男性OR=0.61;95%CI=0.45～0.82;P=0.001),糖尿病(OR=2.21,95%CI=1.67～2.93;P<0.0001),围手术期水化治疗(OR=0.50,95%CI=0.38～0.65,P<0.0001)也是患者对比剂肾病风险的独立预测因素。结论:术前hs-CRP水平与经皮冠状动脉介入治疗术后CI-AKI发生率显著相关。hs-CRP水平可以为患者术前危险分层提供帮助。     

老年急性心肌梗死患者血清降钙素原水平变化与预后的相关性

目的探讨老年急性心肌梗死(AMI)患者血清降钙素原(PCT)水平变化与近期临床预后的关系。方法选择97例老年AMI患者作为病例组,同期体检者80例作为对照组。测定血清PCT和高敏C反应蛋白(hs-CRP)水平,AMI患者根据血清PCT水平分为正常组(<0.5μg/L)23例、轻度升高组(0.5¹.9μg/L)41例和明显升高组(≥2.0μg/L)33例。随访患者30d心源性死亡和主要心血管不良事件(MACE)发生率。结果病例组患者血清PCT、hs-CRP水平明显高于对照组,差异有统计学意义[(3.14±1.59)μg/L vs(0.15±0.04)μg/L,(95.21±20.17)mg/L vs(11.32±9.30)mg/L,P<0.01]。与正常组和轻度升高组比较,明显升高组心源性死亡和MACE发生率显著增加(0%和7.3%vs 24.2%,13.0%和22.0%vs 45.5%,P<0.05)。血清PCT与hs-CRP呈正相关(r=0.4721,P=0.032)。血清PCT可预测老年AMI患者30d心源性死亡和MACE发生率(OR=5.011,OR=4.312,P<0.01)。结论老年AMI患者血清PCT水平升高,对预测近期心源性死亡和MACE有一定参考价值。     

Prognostic significance of the change in glucose level in the first 24 h after acute myocardial infarction: results from the CARDINAL study.

AIMS: In acute myocardial infarction (AMI), baseline hyperglycaemia predicts adverse outcomes, but the relation between subsequent change in glucose levels and outcomes is unclear. We evaluated the prognostic significance of baseline glucose and the change in glucose in the first 24 h following AMI. METHODS AND RESULTS: We analysed 1469 AMI patients with baseline and 24 h glucose data from the CARDINAL trial database. Baseline glucose and the 24 h change in glucose (24 h glucose level subtracted from baseline glucose) were included in multivariable models for 30- and 180-day mortality. By 30 and 180 days, respectively, 45 and 74 patients had died. In the multivariable 30-day mortality model, neither baseline glucose nor the 24 h change in glucose predicted mortality in diabetic patients (n=250). However, in nondiabetic patients (n=1219), higher baseline glucose predicted higher mortality [hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.20, per 0.6 mmol/L increase], and a greater 24 h change in glucose predicted lower mortality (HR 0.91, 95% CI 0.86-0.96, for every 0.6 mmol/L drop in glucose in the first 24 h) at 30 days. Baseline glucose and the 24 h change in glucose remained significant multivariable mortality predictors at 180 days in nondiabetic patients. CONCLUSION: Both higher baseline glucose and the failure of glucose levels to decrease in the first 24 h after AMI predict higher mortality in nondiabetic patients.     

急性心肌梗死后应激性高血糖与心室重构以及预后的关系

目的:探讨急性心肌梗死(AMI)急性期的空腹血糖水平与心室重构之间的相关性以及与1个月、1年死亡率的关系。方法:连续248例非糖尿病AMI患者,排除了其他引起慢性应激的因素,测定患者次日晨起空腹血糖(FG)。AMI后第2周进行超声心动图检查,随访患者1个月和1年的存活情况。进行FG和超声心动图各参数间的相关分析。比较不同血糖水平下的1个月和1年死亡率。结果:①FG与左室射血分数(r=-0.287,P<0.01),左室后壁厚度(r=-0.205,P<0.01)均呈轻度负相关,与左室舒张末径(r=0.166,P<0.05),左室收缩末径(r=0.312,P<0.01)均呈轻度正相关。②合并应激性高血糖者预后较无应激性高血糖者差(1个月死亡率:19.8%vs.7.5%,P<0.01;1年死亡率26.7%vs.12.2%,P<0.01)。血糖重度升高者预后较轻度升高者差(1个月死亡率:33.3%vs.13.2%,P<0.05;1年死亡率42.4%vs.19.1%,P<0.05)。结论:AMI急性期的FG水平作为机体应激程度的标志与左心室重构相关,FG高者,1个月和1年预后均较差。     

Impact of admission hyperglycemia and diabetes mellitus on short- and long-term mortality after acute myocardial infarction in the coronary intervention era

The influence of admission hyperglycemia and diabetes on short- and long-term mortality of patients with acute myocardial infarction (AMI) in the percutaneous coronary intervention (PCI) era was investigated. From 1996 to 2003, a total of 802 consecutive patients with AMI underwent coronary angiography. Primary PCI was performed in 724 patients (90%). Three-year mortality curves were constructed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors of 30-day mortality and mortality from 30 days to 3 years. There were 261 patients with admission hyperglycemia (admission glucose>or=11.1 mmol/L) and 212 patients with diabetes. Admission hyperglycemia was associated with a significantly higher 30-day mortality rate (8.4% vs 2.4%, p<0.001). However, there was no significant difference in 30-day mortality rates between diabetic and nondiabetic patients (5.7% vs 3.9%, p=0.29). Conversely, diabetes significantly increased mortality from 30 days to 3 years (10.0% vs 5.5%, p=0.03), but admission hyperglycemia did not (8.4% vs 5.9%, p=0.19). Multivariate analysis showed that hyperglycemia was an independent predictor of 30-day mortality (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.13 to 2.61, p=0.01), but diabetes was not (OR 0.84, 95% CI 0.55 to 1.27, p=0.42). Diabetes was independently associated with mortality from 30 days to 3 years (OR 1.43, 95% CI 1.02 to 1.97, p=0.04), but hyperglycemia had a neutral effect (OR 0.98, 95% CI 0.70 to 1.36, p=0.92). In conclusion, in the PCI era, admission hyperglycemia was associated with short-term mortality, whereas diabetes increased long-term mortality after convalescence in patients with AMI. Admission hyperglycemia and diabetes should be treated as 2 distinct disease states.     

入院血糖水平与急诊冠状动脉介入治疗术后患者预后的相关性

目的探讨急性心肌梗死（AMI）患者血糖水平与经皮冠状动脉介入（PCI）干预后住院期间心脏不良事件的相关性。方法入选312例初发AMI患者于入院即刻测定静脉血糖,并于发病24h内行急诊PCI。根据入院即刻血糖水平分为高血糖组（血糖〉11mmol／L,44例）和血糖正常组（血糖≤11mmol／L,268例）;按是否合并糖尿病分为糖尿病组（81例）和非糖尿病组（231例）。随访患者住院期间病死率及术后180d心脏不良事件发生率。结果无论是否合并糖尿病,高血糖组住院期间病死率及PCI术后180d心脏不良事件发生率均明显高于血糖正常组（18．2％比3．0％,P〈0．001;25％比12．7％,P=0．047）,多因素分析显示入院即刻血糖为死亡及心脏不良事件的独立预测因素（OR5．15,95％CI 1．74～15．28,P=0．003及OR 2．84,95％CI 1．18～6．83,P=0．019）,而是否合并糖尿病对上述终点无明显影响。结论无论是否合并糖尿病,入院即刻高血糖是AMI患者PCI术后住院期间病死率和180d心脏不良事件的相对独立危险因素。     

Medical comorbidities at admission is predictive for 30-day in-hospital mortality in patients with acute myocardial infarction: analysis of 5161 cases

Background The present study investigated the prognostic value of medical comorbidities at admission for 30-day in-hospital mortality in patients with acute myocardial infarction (AMI). Methods A total of 5161 patients with AMI were admitted in Chinese PLA General Hospital between January 1, 1993 and December 31, 2007. Medical comorbidities including hypertension, diabetes mellitus, previous myocardial infarction, valvular heart disease, chronic obstructive pulmonary disease (COPD), renal insufficiency, previous stroke, atrial fibrillation and anemia, were identified at admission. The patients were divided into 4 groups based on the number of medical comorbidities at admission (0, 1, 2, and ≥ 3). Cox regression analysis was used to calculate relative risk (RR) and 95% confidence intervals (CI), with adjustment for age, sex, heart failure and percutaneous coronary intervention (PCI). Results The mean age of the studied population was 63.9 ± 13.6 years, and 80.1% of the patients were male. In 74.6% of the patients at least one comorbidity were identified. Hypertension (50.7%), diabetes mellitus (24.0%) and previous myocardial infarction (12%) were the leading common comorbidities at admission. The 30-day in-hospital mortality in patients with 0, 1, 2, and ≥ 3 comorbidities at admission (7.2%) was 4.9%, 7.2%, 11.1%, and 20.3%, respectively. The presence of 2 or more comorbidities was associated with higher 30-day in-hospital mortality compared with patients without comorbidity (RR: 1.41, 95% CI: 1.13-1.77, P = 0.003, and RR: 1.95, 95% CI: 1.59-2.39, P = 0.000, respectively). Conclusions Medical comorbidities were frequently found in patients with AMI. AMI patients with more comorbidities had a higher 30-day in-hospital mortality might be predictive of early poor outcome in patients with AMI.     

The association between hyperglycaemia on admission and 180-day mortality in acute myocardial infarction patients with and without diabetes.

AIM: To evaluate the association between hyperglycaemia on admission, previously known diabetes and 180-day mortality in acute myocardial infarction (AMI) patients. METHODS: The study population consisted of 779 consecutive AMI patients from the Myocardial Infarction Registry in Estonia who had an admission venous plasma glucose level recorded and who were admitted to the Tartu University Clinics within a period of 2 years. Logistic regression analysis was used to estimate crude and adjusted odds ratios (OR) with 95% confidence interval (95% CI). RESULTS: In patients without a history of diabetes, glucose level was < or = 11.0 mmol/l in 556 patients (group 1) and > 11.0 mmol/l in 109 patients (group 2). Of those with diabetes, glucose level was < or = 11.0 mmol/l in 30 patients (group 3) and > 11.0 mmol/l in 84 patients (group 4). Non-diabetic hyperglycaemic patients underwent more resuscitations outside of hospital (group 2, 31.2% vs. group 1, 2.0% vs. group 3, 6.7% vs. group 4, 6.0%, P < 0.0001) and had a higher 180-day mortality compared with other groups (group 2, 47.7% vs. group 1, 14.1% vs. group 3, 26. 7% vs. group 4, 29.8%, P < 0.0001). After adjustment for potentially confounding factors, hyperglycaemic non-diabetic (OR 4.35, 95% CI 1.79-10.59), but not diabetic (OR 1.79, 95% CI 0.62-5.15) status, remained an independent predictor of 180-day mortality. CONCLUSIONS: AMI patients with hyperglycaemia on admission, independent of a history of diabetes, represent a high-risk population for 180-day mortality. The worst outcome occurs in non-diabetic hyperglycaemic patients. Further studies are warranted to clarify the questions of hyperglycaemia treatment in AMI patients.     

Prognostic differences between different types of bundle branch block during the early phase of acute myocardial infarction: insights from the Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial.

AIMS: Bundle branch block (BBB) early during acute myocardial infarction (AMI) is often considered high risk for mortality. Little is known about how different BBB types influence prognosis. METHODS AND RESULTS: The HERO-2 trial recruited 17 073 patients with ischaemic symptoms lasting >30 min and either ST elevation with or without right bundle branch block (RBBB) or presumed-new left bundle branch block (LBBB). Electrocardiograms were performed before and 60 min after the start of fibrinolytic therapy. Using patients with normal intraventricular conduction as a reference, odds ratios (ORs) for 30-day mortality were calculated for different BBB types (LBBB, RBBB with anterior AMI, and RBBB with inferior AMI) present at randomization and/or 60 min, with adjustment for recruitment region, pre-infarction characteristics, time to randomization, hemodynamics, and Killip class. At randomization, the 873 patients (5.11%) with BBB had worse baseline characteristics than patients without BBB. In patients presenting with LBBB (n=300), the ORs for 30-day mortality were 1.90 (95% CI 1.39-2.59) before and 0.68 (0.48-0.99) after adjustment for other prognosticators. In patients presenting with RBBB (n=415) and anterior AMI, the ORs were 3.52 (2.82-4.38) before and 2.48 (1.93-3.19) after adjustment. In patients presenting with RBBB and inferior AMI (n=158), the ORs were 1.74 (1.06-2.86) before and 1.22 (0.71-2.08) after adjustment. Within 60 min, 143 patients (0.92%) developed new BBB. The adjusted ORs for 30-day mortality were 2.97 (1.16-7.57) in the 25 patients with new LBBB, 3.84 (2.38-6.22) in the 100 with new RBBB and anterior AMI, and 2.23 (0.54-9.21) in the 18 with new RBBB and inferior AMI. CONCLUSION: RBBB accompanying anterior AMI at presentation and new BBB (including LBBB) early after fibrinolytic therapy are independent predictors of high 30-day mortality. These electrocardiographic features should be considered in risk stratification to identify high-risk patients.     

Analysis with the propensity score of the association between likelihood of treatment and event of interest in observational studies. An example with myocardial reperfusion

INTRODUCTION AND OBJECTIVES: Analysis of the effect of treatment in observational studies is complex due to differences between treated and nontreated patients. Calculating the probability of receiving treatment conditioned on relevant covariates (propensity score [PS]) has been proposed as a method to control for these differences. We report an application of PS to assess the association between reperfusion treatment and 28-day case fatality in patients with acute myocardial infarction (AMI). METHOD: We describe the procedure used to calculate PS for receiving reperfusion treatment, and different strategies to analyze the association between PS and case fatality with regression modeling and matching. Data were from a population-based registry of 6307 patients with AMI in Spain during 1997-98. RESULTS: The PS for reperfusion was calculated in 5622 patients. In the multivariate analysis, reperfusion was associated with lower case fatality (OR = 0.59; 95% confidence interval [95% CI]: 0.46-0.77). When PS was included as a covariate, this association became non- significant (OR = 0.76; 95% CI: 0.57-1.01). In the subgroup of matched patients with a similar PS (n = 3138), treatment was not associated with case fatality (OR = 0.95; 95% CI: 0.72-1.26). When the influence of cases with missing data on PS was controlled for, reperfusion treatment was associated with lower fatality (OR = 0.66; 95% CI: 0.55-0.80). CONCLUSIONS: Calculating propensity score is a method that controls for differences between treated and nontreated patients. This score has limitations when matching is incomplete and when data are missing. Results of the present example suggest that reperfusion treatment reduces AMI case fatality.     

Tissue plasminogen activator on admission is an important predictor of 30-day mortality in patients with acute myocardial infarction undergoing primary angioplasty

Tissue plasminogen activator (tPA) is emerging as an important risk factor for coronary heart disease, but the association between tPA concentration and mortality in acute myocardial infarction (AMI) remains uncertain. We studied the relationship between tPA antigen level on admission and 30-day mortality in 226 consecutive patients with AMI undergoing primary angioplasty. Death within 30 days occurred in 13 patients (5.7%). The concentration of tPA was significantly higher among the 13 patients who died than among the 213 who survived (26.5+/-16.3 versus 12.5+/-8.5 ng/mL, p<0.001). Compared with those in the lowest quartile (<9 ng/mL), patients in the highest quartile (>16 ng/mL) had a relative risk of subsequent death of 13.1 (p=0.014). In a Cox regression model, a tPA concentration >19 ng/mL was independently associated with mortality (HR 12.1, 95% CI, 1.9-76.7, p=0.001). This cutoff value had a 76.9% sensitivity and an 85.9% specificity for predicting 30-day mortality. tPA concentration was also higher in patients with severe heart failure (20.9+/-14.2 ng/mL versus 11.7+/-7.5 ng/mL, p=0.001) or ventricular tachyarrhythmia (24.3+/-13.9 ng/mL versus 12.2+/-8.4 ng/mL, p=0.001). In conclusions, elevated tPA antigen at initial presentation in patients with AMI was associated with higher short-term risk of death, suggesting that tPA may be a useful prognostic biomarker for the early risk stratification of these patients.     

Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes

OBJECTIVES: The purpose of this research was to examine the prognostic value of ST-segment changes (concordant ST-segment elevation and/or precordial V1 to V3 ST-segment depression) during presumed-new left bundle branch block (LBBB) in patients receiving fibrinolytic therapy. BACKGROUND: These patients are often considered high-risk, but their outcome is not well-defined. METHODS: The Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial compared bivalirudin with heparin in patients receiving streptokinase for ST-segment elevation or presumed-new LBBB. Each patient with LBBB was matched with a control (with normal intraventricular conduction) for age, gender, pulse rate, systolic blood pressure, Killip class, and region. RESULTS: A total of 300 patients had LBBB (92 with and 208 without ST-segment changes) and 15,340 had normal conduction. Acute myocardial infarction (AMI) occurred in 80.7% of LBBB patients and 88.7% of controls (p = 0.006). ST-segment changes were specific (96.6%) but not sensitive (37.8%) for enzymatic diagnosis of AMI. Mortality at 30 days was similar in LBBB patients with ST-segment changes (21.7%) and controls (25.0%, p = 0.563), but lower in LBBB patients without ST-segment changes than in controls (13.5% vs. 21.6%, p = 0.022). In the whole HERO-2 cohort, the LBBB patients with ST-segment changes had higher mortality than patients with normal conduction (odds ratio [OR] 1.37, 95% confidence interval [CI] 0.78 to 2.42). The LBBB patients without ST-segment changes had lower mortality than patients with normal conduction (OR 0.52, 95% CI 0.33 to 0.80). CONCLUSIONS: ST-segment changes during LBBB are specific for the diagnosis of AMI and predict 30-day mortality; LBBB patients without ST-segment changes have lower adjusted 30-day mortality than those with normal conduction. Trials are required to determine the best treatment for high-risk and low-risk patients with LBBB.