Associations between ST depression, four year mortality, and in-hospital revascularisation in unselected patients with non-ST elevation acute coronary syndromes

• Published in: British heart journal 2003-05, Vol.89 (5), p.490-495
• Main Authors: Hyde, T A, French, J K, Wong, C-K, Edwards, C, Whitlock, R M L, White, H D
• Format: Article
• Language: English
• Subjects: acute coronary syndrome; Acute coronary syndromes; Analysis of Variance; Biological and medical sciences; CABG; Cardiovascular Medicine; comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban; coronary artery bypass graft; Coronary Disease - mortality; Coronary Disease - surgery; creatine kinase; Diseases of the cardiovascular system; Electrocardiography; Female; Follow-Up Studies; Fragmin and fast revascularisation during instability in coronary artery disease; FRISC II; Heart attacks; Heart diseases; Hospitalization; Humans; interquartile range; IQR; Male; MATE; Medical sciences; medicine v angiography in thrombolytic exclusion trial; Middle Aged; Mortality; Myocardial Revascularization - methods; New Zealand - epidemiology; odds ratio; platelet receptor inhibition in ischaemic syndrome management; PRISM; Prospective Studies; Pulmonary Edema - mortality; Radiotherapy. Instrumental treatment. Physiotherapy. Reeducation. Rehabilitation, orthophony, crenotherapy. Diet therapy and various other treatments (general aspects); randomised interventional trial of unstable angina; revascularisation; RITA; SHOCK; should we emergently revascularise occluded coronaries for cardiogenic shock; Survival Analysis; TACTICS; thrombolysis in myocardial infarction trial; Time Factors; TIMI; treatment of refractory unstable angina in geographically isolated areas without cardiac surgery; TRUCS; VA non-Q-wave infarction strategies in hospital; value of first day angiography/angioplasty in evolving non-ST elevation myocardial infarction: an open multicentre randomised trial; VANQWISH; VINO
• ISSN: 1355-6037; 0007-0769; 1468-201X
• DOI: 10.1136/heart.89.5.490

Objective: To determine the associations between changes on the presenting ECG, in-hospital revascularisation, and four year mortality in patients with non-ST elevation acute coronary syndromes. Design: Prospective evaluation of all consecutive patients admitted in 1993 to the Green Lane Hospital coronary care unit, Auckland, New Zealand. Late follow up was undertaken at a median of 52 months. The ECGs were analysed after the hospital admission. Setting: Tertiary referral centre with direct local coronary care unit admissions. Interventions: Patients underwent physician recommended in-hospital revascularisation or initial conservative management. Results: The four year survival was 88% in the 115 patients who underwent revascularisation (65 (19%) percutaneous and 53 (16%) surgical revascularisation), compared with 75% in 316 patients managed conservatively (p = 0.024). Four year survival for patients undergoing revascularisation versus initial conservative management with respect to ECG groups was: no ECG changes (n = 101), 97% v 92% (p = 0.35); T wave inversion or 0.5 mm ST depression (n = 108), 89% v 78% (p = 0.18); ST depression ≥ 1 mm (n = 122), 80% v 58% (p = 0.014); χ2 = 29, p < 0.001 for the linear trend across the groups. On multivariate analysis, independent predictors of four year mortality were: age (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01 to 1.08; p = 0.0046); ECG group (OR 1.88, 95% CI 1.21 to 2.95; p = 0.043); radiological pulmonary oedema (OR 2.81, 95% CI 1.18 to 7.05; p = 0.025); and revascularisation (OR 0.43, 95% CI 0.20 to 0.90; p = 0.023). Conclusions: Among unselected patients with non-ST elevation acute coronary syndromes, in-hospital revascularisation is associated with decreased mortality at up to four years after admission. This association appears greater in patients with ST depression of ≥ 1 mm on the presenting ECG.