Risk stratification in the patient with ST elevation MI

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Definition

• Chest pain or classic symptoms for more than 30 minutes.
• ST-segment elevation of at least 1 mV in 2 contiguous leads, or new left bundle branch block.
• Increase of cardiac enzyme levels.

Risk stratification in patient presenting with STEMI

• The Thrombolysis in Myocardial Infarction (TIMI) risk score for STEMI:
  • The TIMI risk score for STEMI was created from simple arithmetic sum of independent predictors of mortality weighted according to the adjusted odds ratios from logistic regression analysis.
  • The patient pool (n=14114) came from the Intravenous nPA for Treatment of Infarcting Myocardium Early II trial (TIME II).
  • The TIMI risk score was subsequently validated in an unselected heterogeneous community population through the National Registry of Myocardial Infarction (NRMI) 3 & 4.
• The Global Registry of Acute Coronary Events (GRACE) risk score for ACS:
  • The GRACE risk score was created from a multivariable logistic regression model using ACS patients enrolled in the GRACE registry (N=11389).
  • The GRACE risk score was validated using subsequent cohort of patients enrolled in GRACE (n=3972) and the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial (n=12142).

Primary percutaneous coronary intervention versus thrombolysis therapy

• Several randomized multi-center clinical trials have demonstrated superiority of primary PCI in comparison to thrombolysis. A review of 23 clinical trials found PCI was better than thrombolysis in reducing short term mortality (7% vs 9%; P=0.0002), death excluding the SHOCK trial data (5% vs 7%; p=0.0003), non-fatal reinfarction (3% vs 7%; p<0.0001), stroke (1% vs 2%; p=0.0004) and the combined end point of death, non-fatal reinfarction and stroke (8% vs 14%; p<0.0001) (Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Keeley EC et al; Lancet 2003 Jan 04;361(9351):13-20).
• ACC/AHA guideline on management of STEMI gave the following recommendation regarding to PCI:
  • Class I indication:
    • Expected door to balloon time goal of 90 minutes or less.
    • Duration of symptom is less than 3 hours and the expected door to balloon time minus the expected door to needle time for thrombolysis is less than 1 hour. Otherwise, thrombolysis is generally preferred.
    • Duration of symptom is greater than 3 hours.
    • Patient is in cardiogenic shock and has severe congestive heart failure and/or Killip class III.
  • Class IIa indication:
    • Patient 75 years or above who developes cardiogenic shock within 36 hours of MI onset who can be revascularized within 18 hours of sock.
    • Duration of symptom within 12-24 hours with severe CHF and/or Killip class III, hemodynamic or electric instability, or persistent ischemia.

References

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