The Acute Myocardial Infarction with ST Segment Elevation Udine Registry (Come-to-Udine): predictors of 3 years mortality

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Abstract

Background

Percutaneous coronary intervention (PCI) is considered the best treatment for acute myocardial infarction with ST segment elevation (STEMI), but it is difficult to deliver.

Objectives

To report on long-term mortality predictors in a registry based on a ‘hub and spoke’ model, according to the initial strategy: thrombolysis followed or not by PCI, invasive strategy followed or not by primary PCI and no reperfusion.

Methods and results

From May 2001 to June 2003, 514 patients (mean age 67 ± 12) with STEMI onset less than 12 h (<24 h if pain ongoing) were enrolled, 34% transferred from spoke centers. Patients were stratified according to thrombolysis in myocardial infarction risk score (TRS) and to local high-risk criteria (LHRC, one of the following: contraindication to thrombolysis, cardiogenic shock, anterior or right ventricular location, ST segment elevation in ≥6 leads, Killip class >1 and previous STEMI). Mean TRS score was 4.0 and 53% of patients met LHRC. Thrombolysis was undertaken in 49% of patients, invasive strategy in 29% and no reperfusion in 22%. The latter had higher TRS (4.9) but only 40% met LHRC. Reperfusion time was significantly longer in patients who underwent PCI as compared with those who underwent thrombolysis (223 vs. 120 min, P < 0.0001). Patients in the thrombolysis group had better risk profiles and underwent emergency or elective revascularization within 30 days in 66% of cases. Overall, long-term mortality rate (36 months) was 23.3%. Both TRS and LHRC identified patients with higher mortality (43 and 32%, respectively). Multivariate analysis showed age, left ventricular ejection fraction and Killip class more than 1 to be significant predictors of mortality (P < 0.0001/P < 0.0001/P = 0.0103), whereas reperfusion strategy and time to treatment were not.

Conclusion

An initial strategy of thrombolysis followed by emergency or elective PCI as appropriate is still an option in a setting in which limited resources are available. Decision-making based on risk scores and time from symptom onset lead to proper patient selection and even to foregoing reperfusion without affecting mortality.

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