Elsevier

International Journal of Cardiology

Volume 228, 1 February 2017, Pages 615-620
International Journal of Cardiology

Very low risk ST-segment elevation myocardial infarction? It exists and may be easily identified

https://doi.org/10.1016/j.ijcard.2016.11.276Get rights and content

Abstract

Background

Early discharge protocols have been proposed for ST-segment elevation myocardial infarction (STEMI) low risk patients despite the existence of few but significant cardiovascular events during mid-term follow-up. We aimed to identify a subgroup of patients among those considered low-risk in which prognosis would be particularly good.

Methods

We analyzed 30-day outcomes and long-term follow-up among 1.111 STEMI patients treated with reperfusion therapy.

Results

Multivariate analysis identified seven variables as predictors of 30-day outcomes: Femoral approach; age > 65; systolic dysfunction; postprocedural TIMI flow < 3; elevated creatinine level > 1.5 mg/dL; stenosis of left-main coronary artery; and two or higher Killip class (FASTEST). A total of 228 patients (20.5%), defined as very low-risk (VLR), had none of these variables on admission. VLR group of patients compared to non-VLR patients had lower in-hospital (0% vs. 5.9%; p < 0.001) and 30-day mortality (0% vs. 6.25%: p < 0.001). They also presented fewer in-hospital complications (6.6% vs. 39.7%; p < 0.001) and 30-day major adverse events (0.9% vs. 4.5%; p = 0.01). Significant mortality differences during a mean follow-up of 23.8 ± 19.4 months were also observed (2.2% vs. 15.2%; p < 0.001). The first VLR subject died 11 months after hospital discharge. No cardiovascular deaths were identified in this subgroup of patients during follow-up.

Conclusions

About a fifth of STEMI patients have VLR and can be easily identified. They have an excellent prognosis suggesting that 24–48 h in-hospital stay could be a feasible alternative in these patients.

Introduction

ST-segment elevation myocardial infarction (STEMI) is a major worldwide concern with a year incidence of 60 to 100/100.000 [1]. In the last decades, decreasing trends in this incidence in parallel with a decline in mortality rates have been reported [2]. An increase in the use and quality of reperfusion therapies, mainly primary percutaneous coronary intervention (PCI), together with the development of new antithrombotic treatments are hypothesised as the main reasons for this reduction [3]. Notwithstanding, mortality rates, despite different between patient categories, are still significant, with current reported overall in-hospital death rates up to 5–10% [1], [4]. Furthermore, healthcare costs associated with STEMI hospitalization are high, especially in the PCI era [5], [6]. In this regard, there is a growing interest on identifying low-risk groups of patients in which an early discharge strategy (48–72 h) would be feasible and safe. This may lead to a decrease in lengths of stay (LOS), and, subsequently, healthcare costs and resources use. A previous early discharge risk score has been published [7], and early discharge protocols have proven to be a valid alternative for low-risk patients [8], [9], [10], [11], [12], [13], [14], who may represent up to 50–70% of all STEMI subjects [11], [14]. However, cardiovascular events and STEMI-related complications according to previous evidence still occur in this subgroup of patients [8], [9], [11], [12], mainly during medium-term follow-up.

Our objective was to identify STEMI patients with excellent short and long-term follow up, as the identification of these very-low-risk (VLR) subjects could safely result in very-early discharge protocols (24 h) [15].

Section snippets

Study population

Patients were identified from the prospectively collected registry DIAMANTE (Descripción del Infarto Agudo de Miocardio: Actuaciones, Novedades, Terapias y Evolución — Description of Acute Myocardial Infarction: Management, New Therapies and Evolution). This database includes patients with STEMI admitted to the Coronary Intensive Care Unit of the Gregorio Marañón General Hospital (Madrid, Spain), a primary PCI-capable tertiary centre with a spoke-hub distribution (connected to several secondary

Results

A total of 1111 patients were included in the final analysis, 853 were males (76.8%). Mean age was 64.1 ± 14.0 years. Nine patients were missing at 30-day follow-up (0.8%), and long-term follow-up data could not be recorded in 22 patients (2.0%). Mean follow-up was 23.8 ± 19.4 months.

Multivariate analysis identified seven variables as predictors of the primary endpoint: Femoral approach; age > 65; systolic dysfunction; postprocedural TIMI flow < 3; elevated creatinine level > 1.5 mg/dL; stenosis of

Discussion

The main finding of our study is that, in conscious-arriving STEMI patients undergoing reperfusion therapy, approximately one fifth present excellent short- and long-term prognosis. The identification of such patients can be easily performed within the first 24 h after first medical contact using the FASTEST score. In this subgroup, non-fatal in-hospital complications that may defer hospital discharge and influence outcomes were all diagnosed within the first day.

In the last decades, especially

Limitations

The main limitations of our study are those applicable to all retrospective and unicentric analyses. In addition, a modest sample size also has to be considered as a limitation, especially when identifying multiple predictors with a low rate of events per variable. The fact that the group of patients considered VLR had an excellent outcome might be, in part, attributable to a longer in-hospital stay, as it may be argued that a more complete treatment might be initiated before discharge together

Conclusion

A fifth of STEMI patients has VLR and can be easily identified using the FASTEST score. Prognosis of this selected group is remarkable good within the first year. Very early discharge protocols (24–48 h) might be safely implemented in this subgroup of patients.

Funding support

This work was partially supported by the Red de Investigación Cardiovascular (RiC), Instituto de Salud Carlos III, Madrid, Spain (RD120042/0001).

Conflicts of interest

None.

Acknowledgments

None.

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    1

    All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

    2

    The authors report no relationships that could be construed as a conflict of interest.

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