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The electrocardiographic window of opportunity to treat vs. the different evolving stages of ST-elevation myocardial infarction: correlation with therapeutic approach, coronary anatomy, and outcome in the DANAMI-2 trial

2007; Oxford University Press; Volume: 28; Issue: 24 Linguagem: Inglês

10.1093/eurheartj/ehm428

1522-9645

Markku Eskola, Lene Holmvang, Kjell Nikus, Samuel Sclarovsky, Hans Henrik Tilsted, Heini Huhtala, Kari Niemelä, Peter Clemmensen,

Cardiac electrophysiology and arrhythmias

The aim of the study was to assess two distinct 12-lead electrocardiogram (ECG) patterns and their prognostic value with respect to reperfusion strategy.In a DANAMI-2 substudy (n = 1522), we defined the pre-infarction syndrome (PIS) as ST-elevation accompanied by positive T waves and evolving myocardial infarction (EMI) as pathological Q waves and/or negative T wave. We used a composite of death, clinical re-infarction, or disabling stroke at median 2.7 year follow-up. A higher overall event rate was observed in the EMI group compared with the PIS group [11.4 (9.4-13.9) and 6.9 (6.0-8.0) per 100 person-years, respectively, ratio of the rate (RR) 1.6, P < 0.001]. The EMI pattern was independently predictive of adverse outcome in multivariable analysis (hazard ratio 1.52, confidence interval 1.01-2.30, P = 0.04). The PIS pattern (n = 952) was associated with lower overall event rate in patients treated with primary percutaneous coronary intervention (PCI) compared with fibrinolytic therapy (FT) [5.5 (4.4-6.9) and 8.5 (7.0-10.4) per 100 person-years, respectively, RR = 0.6, P = 0.004]. No significant difference in the outcome between treatment strategies was observed in the EMI group as a whole. However, in patients with anterior EMI without ECG signs of reperfusion, superiority of primary PCI was driven by a 51% reduction in the relative risk of composite endpoint (P = 0.008).More detailed ECG analysis, involving also Q- and T-wave morphology, is useful for rapid identification of high-risk patients in whom every effort should be made to transfer for primary PCI, or vice versa, for identifying low-risk patients in whom FT might be an alternative option.