Prognostic utility of quantifying evolutionary ST-segment depression on early follow-up electrocardiogram in patients with non-ST-segment elevation acute coronary syndromes

• Published in: European heart journal 2010-04, Vol.31 (8), p.958-966
• Main Authors: Yan, Raymond T., Yan, Andrew T., Mahaffey, Kenneth W., White, Harvey D., Pieper, Karen, Sun, Jie-Lena, Pepine, Carl J., Biasucci, Luigi M., Gulba, Dietrich C., Lopez-Sendon, Jose, Goodman, Shaun G.
• Format: Article
• Language: English
• Subjects: Acute Coronary Syndrome - diagnosis; Acute Coronary Syndrome - mortality; Acute coronary syndromes; Aged; Biological and medical sciences; Cardiology. Vascular system; Coronary heart disease; Death, Sudden, Cardiac - epidemiology; Electrocardiogram; Electrocardiography - methods; Electrocardiography - mortality; Female; Heart; Hospitalization; Humans; Incidence; Kaplan-Meier Estimate; Male; Medical sciences; Myocardial Infarction - mortality; Myocarditis. Cardiomyopathies; Prognosis; Prospective Studies; Recurrence; Risk Factors
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehp548

Aims Although ST-segment depression (STD) on the admission electrocardiogram (ECG) confers adverse prognosis in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), the implications of STD on follow-up ECG remain uncertain. We determined the prognostic significance of STD on follow-up ECG performed within 12–24 h of admission and whether its quantitative evaluation can further refine risk stratification. Methods and results The admission and follow-up ECGs of 3877 patients in the SYNERGY trial were analysed for the presence (≥1 mm) and extent (maximum magnitude on any single lead) of STD. Of the 1110 patients presenting with STD on admission, 534 (48.1%) with persistent STD at follow-up had higher mortality at 30 days (7.1 vs. 3.6%, P = 0.01) and 6 months (10.7 vs. 5.2%, P = 0.001) than those with normalized STD. Among 2767 patients without STD on admission, 174 (6.3%) developed new STD on follow-up ECG and experienced increased mortality compared with those without such interval change (30 days: 4.0 vs. 1.7%, P = 0.035; 6 months: 8.0 vs. 3.3%, P = 0.001). After adjustment for established clinical prognosticators and the extent of STD on admission, every 1 mm increment of STD on the follow-up ECG independently predicted a graded increase in 30-day mortality [hazards ratio (HR) = 1.60, 95% confidence interval (CI) = 1.29–1.98, P < 0.0001], and death/myocardial infarction at 30 days (HR = 1.19, 95% CI = 1.03–1.36, P = 0.017) and 6 months (HR = 1.17, 95% CI = 1.03–1.32, P = 0.016). Conclusion The magnitude of STD on a routine 12–24 h follow-up ECG provides incremental prognostic information beyond established clinical prognosticators and the extent of STD on admission. Incorporating a follow-up ECG and its quantitative evaluation for STD may further refine risk stratification of patients with NSTE-ACS.