Usefulness of hospital admission risk stratification for predicting nonfatal acute myocardial infarction or death six months later in unstable angina pectoris

doi:10.1016/S0002-9149(99)00481-6

The American Journal of Cardiology

Volume 84, Issue 9, 1 November 1999, Pages 963-969

https://doi.org/10.1016/S0002-9149(99)00481-6 Get rights and content

Abstract

The aim of this study was to assess the clinical course of unstable angina and the prognostic value of clinical and electrocardiographic variables measured during admission in a prospective, multicenter cohort study with 6-month follow-up. The population corresponds to 4 general teaching hospitals in Catalonia, Spain. The clinical course was analyzed in 839 consecutive patients aged up to 80 years with primary unstable angina, without myocardial infarction or previous coronary bypass. The main outcome measures were cardiac mortality and nonfatal myocardial infarction. Patients involved in the present analysis belonged to the Resources Used in Acute Coronary Syndromes and Delays in Treatment (RESCATE) study. Six-month overall mortality, cardiac mortality, and nonfatal myocardial infarction rates were 4.6%, 4.1%, and 3.9%, respectively. Six-month cardiac mortality or myocardial infarction rate did not differ among clinical forms of presentation. Peripheral artery disease (RR 3.5, 95% confidence interval [CI] 1.88 to 6.50, p = 0.0001), ST-T-wave electrocardiographic changes on admission (RR 2.22, 95% CI 1.13 to 4.36, p = 0.0203), and age >65 years (RR 1.74, 95% CI 1.04 to 2.91, p = 0.0356) independently predicted 6-month cardiac mortality or nonfatal myocardial infarction. Their positive predictive values were 21%, 10%, and 11%, respectively, whereas their negative predictive value was ≥93% in all cases. Prevalences were 9%, 70%, and 41%, respectively. In this prospective study, patients with unstable angina without prior myocardial infarction have a relatively low, although not negligible, 6-month severe complication rate. Stratification risk can easily be established with clinical and electrocardiographic characteristics measured during admission. Their absence almost rules out future adverse events, while their presence does not necessarily imply bad prognosis.

Section snippets

Patients

Between March 1992 and August 1994, 839 consecutive patients with primary unstable angina were admitted to 4 teaching general hospitals in Catalonia, Spain, as part of a prospective multicenter study called Resources Used in Acute Coronary Syndromes and Delays in Treatment (RESCATE5), the aims of which were to ascertain whether accessibility to coronary angiography, depending on the on-site availability of this procedure, determined different use rates or delays in patients with acute coronary

Clinical characteristics

A total of 2,661 patients with unstable angina were consecutively admitted to the participating hospitals. Of these patients, 839 (31.5%) fulfilled the study inclusion criteria. The most frequent causes for exclusion were previous myocardial infarction (50%), prior inclusion in the registry (17%), age >80 years (9%), coexisting life-threatening illness (7%), previous coronary artery bypass surgery (6%), cardiac catheterization or percutaneous transluminal coronary angioplasty in the previous 6

Clinical course

This study shows that total mortality and nonfatal acute myocardial infarction rate were relatively low in a large series of 839 patients with primary unstable angina with no history of myocardial infarction or bypass graft surgery and treated according to a previously defined protocol. In the last decade the prognosis of these patients has improved. Previous series6, 7, 8, 9 showed 3% to 4% and 6% in-hospital and 3-month mortality, respectively. Groups treated with placebo in multicenter

Acknowledgements

We thank Marta Pulido, MD, for editorial assistance and copy editing and Christine O’Hara for English revision of the final version.

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Cited by (21)

Determinants of coronary events in patients with stable angina: Results from the Impact of Nicorandil in Angina Study
2005, American Heart Journal
Citation Excerpt :
Although individual factors in the models had high statistical significance in their relation to outcome, this does not mean that the models are likely to be effective in accurately predicting the time until an event will occur in an individual patient.27 A previous study in patients with unstable angina, but who had no previous MI or CABG, found that electrocardiographic changes had a high sensitivity (84%) but a low specificity (30%) for detecting cardiac mortality and nonfatal MI.28 In our study, if we combine the CCS angina grades of III and IV as a potential “test,” we have a sensitivity of 20% and a specificity of 90% for the primary end point, or 21% and 89%, respectively, for the secondary end point.
IONA was a randomized trial of nicorandil (20 mg twice daily) versus placebo in 5126 patients with stable angina of effort. We present the characteristics as measured at baseline that were found to be associated with increased risk of major outcomes.
The primary end point of the study was coronary heart disease death, nonfatal myocardial infarction (MI), or unplanned hospitalization for cardiac chest pain. The secondary outcome excluded the softer outcome of unplanned hospitalization for chest pain. Potential prognostic factors included nicorandil treatment, sex, smoking, severity of angina (Canadian Cardiovascular Society [CCS] grading), previous MI, coronary artery bypass graft/percutaneous transluminal coronary angioplasty (CABG/PTCA), left ventricular dysfunction, left ventricular hypertrophy (LVH) on electrocardiography (ECG), histories of diabetes or hypertension, baseline cardiovascular drugs, age, blood pressures, heart rate, height, weight, and body mass index.
A total of 5047 patients had complete baseline information. There were 724 primary outcomes and 240 secondary outcomes. The strongest determinants of the hard secondary end point were CCS score (hazards ratio [HR] 2.25, 95% confidence intervals [CI] 1.50-3.38) for grades III and IV versus grade I, age (HR 1.23, 95% CI 1.13-1.33) for 5-year risk, and previous MI (HR 2.05, 95% CI 1.48-2.85). The results for the primary outcome were similar, with stronger associations with LVH on ECG and smoking, and a weaker association with age.
We present models of risk factors for coronary outcomes in a population with angina of effort. The strongest risk factors were the CCS score and previous MI.
Clinical characteristics, prognosis, and variability in the management of non-ST-segment elevation acute coronary syndromes. Data from the PEPA registry
2003, Revista Espanola de Cardiologia
Conocer el perfil clínico y la variabilidad interhospitalaria en el tratamiento y pronóstico de los pacientes con síndrome coronario agudo sin elevación del segmento ST.
Se analizaron los datos del estudio PEPA, registro prospectivo que incluyó a 4.115 pacientes ingresados en 18 hospitales españoles.
La edad media fue de 65 años, un 33% eran mujeres y un 26%, diabéticos. Se observaron grandes diferencias en el tipo de pacientes ingresados en cada centro, especialmente en los antecedentes patológicos, revascularización coronaria previa y comorbilidad. El 93% de los pacientes recibieron tratamiento antiagregante, el 45%, heparina, el 42%, bloqueadores beta, el 67%, nitratos y el 46%, antagonistas del calcio. Durante el ingreso se realizó una ergometría al 37% de los pacientes, coronariografía al 32%, angioplastia coronaria al 9% y cirugía de revascularización al 4%. La variabilidad fue mínima en la administración de antiagregantes plaquetarios, importante en la de heparina y bloqueadores beta, y muy marcada en el uso de procedimientos de revascularización. La mortalidad y la incidencia de muerte o infarto fue del 2,6 y 4,4% durante la hospitalización, y del 4,6 y 8% a los 3 meses, con una amplia variabilidad interhospitalaria. Estas diferencias dejaron de ser significativas tras ajustar por las características clínicas y el tratamiento recibido en el momento del ingreso.
Los pacientes con síndrome coronario agudo sin elevación del segmento ST forman un grupo heterogéneo con una elevada incidencia de complicaciones y con una gran variabilidad interhospitalaria en su manejo terapéutico, tanto farmacológico como, sobre todo, invasivo. Estos resultados resaltan la importancia de la correcta estratificación inicial del riesgo y la homo-geneización de su tratamiento, siguiendo las recomendaciones de las guías de práctica clínica.
To assess the clinical characteristics and inter-hospital variability in the treatment and prognosis of patients with non-ST-segment elevation acute coronary syndromes.
Data from the PEPA study, a prospective registry that enrolled 4,115 patients in 18 Spanish hospitals, were analyzed.
The mean age of the patients enrolled was 65 years, 33% were women, and 26% had diabetes. Large differences were observed in the clinical profile of patients admitted to different centers, especially relative the history of previous disease, prior coronary revascularization, and co-morbidity. Antiplatelet treatment was used in 93% of patients, heparin in 45%, beta-blockers in 42%, nitrates in 67%, and calcium antagonists in 46%. During hospitalization, exercise stress testing was performed in 37% of patients, coronary angiography in 32%, coronary angioplasty in 9%, and coronary surgery in 4%. Inter-hospital variability was minimal for the use of anti-platelet agents, wide for the use of heparin and beta-blockers, and huge for the use of revascularization procedures. Mortality and the incidence of death or myocardial infarction were 2.6% and 4.4% during hospitalization, and 4.6% and 8% at 3 months, with wide inter-hospital variability. These differences were not significant once adjusted for clinical characteristics and the treatment received at admission.
Patients with non-ST-segment elevation acute coronary syndromes represent an heterogeneous group with a high incidence of complications. Pharmacologic and, especially, invasive treatment varies widely in different hospitals. These results underline the importance of correct initial risk stratification and uniform treatment following the recommendations of clinical guidelines.
Prognosis factors in unstable angina with dynamic electrocardiographic changes. Value of fibrinogen
2002, Revista Espanola de Cardiologia
El pronóstico de la angina inestable varía entre diferentes series según los criterios de inclusión. El objetivo ha sido evaluar los episodios hospitalarios y sus predictores en una serie homogénea de angina inestable.
Se incluyó a 246 pacientes consecutivos con los siguientes criterios: a) dolor anginoso en reposo; b) cambios electrocardiográficos dinámicos durante el dolor; c) CK-MB normal, y d) angina post-infarto excluida. Se trataron con aspirina y enoxaparina (1 mg/kg/12 h) y se efectuó coronariografía en caso de angina recurrente o isquemia en el estadio I-II de Bruce en el test de esfuerzo prealta. Se recogieron los factores de riesgo, historia previa de cardiopatía isquémica, historia de cirugía coronaria, electrocardiograma durante el dolor y fibrinógeno.
Durante el ingreso se presentaron los siguientes episodios: 36%, angina recurrente; 58%, cateterismo cardíaco y 5,7%, episodios mayores (infarto o muerte). Mediante análisis multivariado se observó que la angina recurrente fue más frecuente con antecedentes de cirugía coronaria (p = 0,004; OR = 22; IC del 95%, 3–182), desviación del segmento ST (p = 0,01; OR: 4,7; IC del 95%, 1,4–15,9) y mayor fibrinógeno (p = 0,002; OR = 1,4; IC del 95%, 1,1–1,7). El fibrinógeno fue la única variable relacionada con la necesidad de cateterismo (p = 0,009; OR = 1,3; IC del 95%, 1,1–1,6) y episodios mayores (p = 0,001; OR = 2,0; IC del 95%, 1,4–3,1).
a) La angina inestable con cambios electrocardiográficos se acompaña de una alta tasa de episodios hospitalarios, y b) los valores elevados de fibrinógeno se asocian con todos los episodios desfavorables, y los antecedentes de cirugía coronaria y la desviación del ST con angina recurrente.
The prognosis of unstable angina varies between series depending on the inclusion criteria and management protocol used. The aim of this study was to analyze in-hospital events and their predictors in a homogeneous single-center series of patients with unstable angina.
A total of 246 patients with the following inclusion criteria were studied: 1) resting anginal pain, 2) transient electrocardiographic changes during anginal pain, 3) normal CK-MB levels and 4) exclusion of postinfarction angina. All patients were treated with aspirin and enoxaparin (1 mg/kg/12 h). Coronary angiography was performed in the case of recurrent angina or ischemia in Bruce I-II stage during the predischarge effort stress test. The variables recorded were risk factors, history of ischemic heart disease, history of coronary surgery, ECG upon admission, and fibrinogen.
During the hospital stay the following events were recorded: 36% recurrent angina, 58% cardiac catheterization, and 5,7% major events (infarction or death). Multivariate analysis found recurrent angina to be more frequent in patients with a history of coronary bypass surgery (p = 0.004. OR = 22; CI 95%, 3–182), ST-segment changes (p = 0.01. OR = 4.7, CI 95%; 1.4–15.9) and higher fibrinogen (p = 0.002. OR = 1,4, CI 95%; 1.1–1.7). Fibrinogen was the only variable related to cardiac catheterization (p = 0,009. OR = 1.3. CI 95%, 1.1–1.6) and major events (p = 0.001. OR = 2.0. CI 95%, 1.4–3.1).
1) Unstable angina with electrocardiographic changes was associated to a high rate of in-hospital events. 2) Fibrinogen was related to any event, and previous by-pass surgery and ST changes were related to recurrent angina.
Modification of risk factors in the young arteriosclerotic patient: Mechanisms involved
2002, Angiologia
Peripheral arteriopathy is an expression of arteriosclerosis which is associated with a poor prognosis. Treatment of it should therefore include measures to reduce its high cardiovascular morbimortality. The palliative measures should be accompanied by the detection and intensive treatment of the main cardiovascular risk factors. In particular smoking, diabetes mellitus and hypertension should be considered.
The preventive measures should be full and equivalent to the measures for secondary preventive measures in persons who already have ischaemic cardiopathy.
Reduction of the high morbimortality due to cardiovascular disease requires an aggressive, multi-disciplinary approach and effort.
La arteriopatía periférica constituye una expresión de arteriosclerosis asociada a mal pronóstico y, por tanto, su tratamiento debe incluir todas las medidas que contribuyan a reducir su elevada morbimortalidad cardiovascular. Las medidas paliativas deben acompañarse de la detección y el tratamiento intensivo de los principales factores de riesgo cardiovascular; en particular, el consumo de tabaco, la diabetes mellitusy la hipertensión deben considerarse prioritarios.
Los objetivos preventivos deben ser máximos y equivalentes a las medidas de prevención secundaria en sujetos que ya tienen cardiopatía isquémica.
La disminución de la elevada morbimortalidad por enfermedad cardiovascular precisa un abordaje y un esfuerzo multidisciplinario y agresivo.
A arteriopatia periférica constitui uma expressão de arteriosclerose associada a prognóstico desfavorável e, portanto, o seu tratamento deve incluir todas as medidas que contribuam para reduzir a sua elevada morbimortalidade cardiovascular. As medidas paliativas devem ser acompanhadas pela detecção e o tratamento intensivo dos principais factores de risco cardiovascular. Em particular, o consumo de tabaco, a diabetes mellitus e a hipertensão, devem considerar-se prioritários.
Os objectivos preventivos devem ser máximos e equivalentes as medidas de prevenção secundária em individuos que já têm cardiopatia isquémica.
A diminuição da elevada morbilidade e mortalidade por doença cardiovascular necessita de uma abordagem e de um esforço multidisciplinar e agressivo.
A risk score system for predicting adverse outcomes and magnitude of benefit with glycoprotein IIb/IIIa inhibitor therapy in patients with unstable angina pectoris
2001, American Journal of Cardiology
Citation Excerpt :
In using logistic regression to develop our risk score, we minimized the risk of “overfitting” the data by ensuring that the ratio of number of events to potential predictors was >10.8 Our findings are also in agreement with other studies that have identified advanced age,9–13 previous CABG,14 prior aspirin use,12,15 and ST depressions9,10,13,16,17 as independent risk factors. Furthermore, use of this risk score system was validated using a different cohort of patients with unstable angina.
Clinical outcomes of patients with unstable angina are variable. We sought to identify predictors of adverse clinical outcomes in patients with unstable angina and to investigate whether these factors would predict the magnitude of benefit achieved with platelet glycoprotein IIb/IIIa inhibition. We analyzed 20 variables in the 1,915 patients enrolled in the Platelet Receptor Inhibition for Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms trial. Five independent predictors were identified: age >65 years, prior coronary artery bypass grafting, antecedent aspirin use, antecedent β-blocker use, and ST depressions on the presenting electrocardiogram. A risk score system was created using these predictors in which patients were assigned 1 point for the presence of each risk factor. There was a progressive increase in the rate of the composite end point of death, myocardial infarction, or refractory ischemia at 7 days with an increasing number of risk factors. For patients treated with heparin alone, the composite end point event rate was 6.5% in the group with 0 or 1 predictor, 14.6% in the group with 2 predictors, 22.7% in the group with 3 predictors, and 37.1% in the group with 4 or 5 predictors (p <0.00001). When dividing patients into low- (0 or 1 point), medium- (2 or 3 points), and high-risk (4 or 5 points) groups, the addition of tirofiban to heparin therapy was associated with no significant benefit in the low-risk group, a 5.2% absolute reduction in the medium-risk group (p = 0.05), and a 16% absolute reduction in the high-risk group (p = 0.0055). Thus, we have developed a risk score system using 5 variables that can be used to identify patients at high risk for death and cardiac ischemic events and who experience the greatest benefit from the addition of a glycoprotein IIb/IIIa inhibitor to their treatment regimen.
Cardiac risk stratification for postmyocardial infarction dental patients
2001, Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics
Citation Excerpt :
Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management and assessment of MIs have recently been published.44 These guidelines provide for early risk stratification during convalescence from an MI,44 which has been validated in some studies.45 O’Rourke46 has reported that up to one half of the 15% to 30% post-MI patients who may be at high risk during the first year can be identified on the basis of clinical characteristics during the first 4 days of convalescence.
Traditional dental management guidelines of myocardial infarction survivors mandate a 6-month waiting period before elective treatment can be considered. Technological advances in cardiac disease diagnosis, management, and revascularization treatment may make this older mandatory 6-month waiting period obsolete. The purposes of this literature review are to provide an overview of the historical development of cardiac risk stratification and discuss current developments and guidelines in cardiac risk assessment. We hope that this review and update will stimulate the development of updated dental guidelines for treating the cardiac patient. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:676-81)

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^☆: This project was funded in part by Grant 92/0009 from the Fondo de Investigación Sanitaria, Madrid; and by Grant CIRIT 1997 SGR 00218 from the Generalitat de Catalunya, Barcelona, Spain.

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Coronary Artery DiseaseUsefulness of hospital admission risk stratification for predicting nonfatal acute myocardial infarction or death six months later in unstable angina pectoris☆

Abstract

Section snippets

Patients

Clinical characteristics

Clinical course

Acknowledgements

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

Unstable angina. A classification

Circulation

Incidence and follow-up of Braunwald subgroups in unstable angina pectoris

J Am Coll Cardiol

Risk stratification in unstable angina. Prospective validation of the Braunwald classification

JAMA

Long term prognosis in unstable angina. The importance of early risk stratification using continuous ST segment monitoring

Eur Heart J

The high-risk angina patient. Identification by clinical features, hospital course, electrocardiography and technetium-99m stannous pyrophosphate scintigraphy

Circulation

Early treatment of unstable angina in the coronary care unita randomised, double blind, placebo controlled comparison of recurrent ischaemia in patients treated with nifedipine or metoprolol or both

Br Heart J

Coronary Artery Disease
Usefulness of hospital admission risk stratification for predicting nonfatal acute myocardial infarction or death six months later in unstable angina pectoris☆