Skip Navigation

European Journal of Heart Failure 2001 3(5):569-576; doi:10.1016/S1388-9842(01)00170-2
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (4)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Nicolau, J. C.
Right arrow Articles by Ramires, J. A.F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nicolau, J. C.
Right arrow Articles by Ramires, J. A.F.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© 2001 European Society of Cardiology

Prognosis of acute myocardial infarction in the thrombolytic era: medical evaluation is still valuable

José C. Nicolaua,*, Carlos V. Serrano, Jr.a, Sérgio A.C. Garzonb and José A.F. Ramiresa

a Heart Institute (InCor),University of São Paulo Medical School Brazil
b Instituto de Moléstias Cardiovasculares São José do Rio Preto, SP, Brazil

* Corresponding author. Rua Aureliano Coutinho 355-14° andar, São Paulo, SP 01224-020, Brazil. Tel.: 55-11-3069-5058; fax: +55-11-3088-3809. E-mail address: corjnicolau{at}incor.usp.br (J.C. Nicolau)


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Background: Modern and sophisticated technology for the management of myocardial infarction has progressively devalued medical evaluation.

Hypothesis: This study was undertaken to assess the importance of the findings of medical evaluation at hospital presentation, in patients with acute myocardial infarction.

Methods: Data from 590 thrombolytic-treated myocardial infarction patients were analyzed. The patients were grouped according to their clinical status on arrival at hospital. A modified Forrester classification — subset II was divided according to the absence (IIa) or presence (IIb) of symptoms — was applied. Short- (14 days) and long-term (up to 10 years) survival was analyzed and 19 independent variables were included in the multivariate models.

Results: Short-term survival was 95.6% for subset I, 83.3% for subset IIa, 60% for subset IIb, 54.6% for subset III, and 34.8% for subset IV (P < 0.001). By multiple regression analysis, lower clinical subsets (P < 0.001), fewer coronary arteries with disease (P = 0.006), younger age (P = 0.014), absence of reinfarction (P = 0.034), longer interval between streptokinase infusion and coronary arteriography (P = 0.016), and higher left ventricular ejection fraction (P = 0.037) demonstrated significant and independent correlation with short-term survival. Long-term survival for the total population was 71 ± 3.6% for subset I, 54.4 ± 8.5% for subset IIa, 20.8 ± 9.4% for subset IIb, 54.5 ± 15% for subset III, and 0% for subset IV (P < 0.001). Using Cox regression analysis, lower clinical subsets (P < 0.001), younger age (P < 0.001), higher global left ventricular ejection fraction (P < 0.001), and fewer coronary arteries with disease (P = 0.021) correlated independently and significantly with long-term survival. When excluding data from patients who died before the short-term follow-up (n = 532), lower clinical subsets remained an important predictor of long-term survival (P < 0.001).

Conclusion: Clinical classification at hospital presentation is a powerful predictor of short- and long-term survival post-myocardial infarction.

Key Words: Acute myocardial infarction • Medical evaluation • Long-term follow-up • Thrombolysis

Received September 19, 2000; Revised December 12, 2000; Accepted January 19, 2001


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Substantial improvement in the management of acute myocardial infarction has occurred over recent years as a result of meaningful findings in basic myocardial research and through randomized clinical trials [1–4]. Clinicians now have a variety of treatment strategies to restore obstructed coronary blood flow and interrupt the evolving ischemic myocardial event. Despite these therapeutic advances, recent large-scale, randomized clinical trials have reported 6–9% early (30–35 days) mortality rates, even for patients receiving thrombolytic therapy within 6 h of symptom onset [5–7]. Often, choices among alternative therapies or decisions regarding the allocation of clinical resources are based on an appraisal of patient risk upon hospital presentation. Careful attention to pivotal factors that increase the risk of early mortality might elucidate the role of second-tier interventions or adjunctive pharmacotherapeutics that would further lower the fatality rate associated with acute myocardial infarction.

To be useful, a risk-assessment evaluation should include clinically relevant prognostic indicators and should be derived from a population representing patients seen in clinical practice, so that true risk factors can be assessed. A useful model should appropriately weigh clinical variables and be validated in a broad spectrum of patients from a variety of hospital settings. Though many studies have attempted to define the prognosis of patients with myocardial infarction or provide risk algorithms or both, [8,9], these studies have been limited by small sample sizes, diverse medical care systems, restricted spectrum of clinical data, and the lack of long-term evaluation of the post myocardial infarction period.

The aim of this study was to conduct a comprehensive analysis of the relationship between clinical and laboratory factors, and short- and long-term survival after thrombolytic therapy, in a cohort of patients who presented with acute myocardial infarction. Our objective was to determine the role of medical evaluation at hospital presentation, in predicting patient survival at 14-days and up to 10-years follow-up, since this type of analysis has not been described before


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
2.1. Study population
This study was part of a population-based investigation of temporal trends in the incidence and case fatality rates of patients hospitalized with acute myocardial infarction. Between October 1985 and February 1995, a total of 612 consecutive patients with acute myocardial infarction, admitted to a single center (Instituto de Moléstias Cardiovasculares, São José do Rio Preto, SP, Brazil) and treated with intravenous streptokinase, 20 min–6 h after the onset of symptoms, were included prospectively and consecutively in a database. The cohort for the present study comprised the 590 patients for whom a complete clinical evaluation could be obtained. This population's characteristics are described in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1 Characteristics of the study population

 
The inclusion criteria were patients with acute myocardial infarction as described below. The exclusion criteria were based on contra-indications to thrombolytic therapy and included any disease in terminal phase, hemorrhagic coagulopathy, stroke in the last 3 months, urinary, or digestive bleeding in the last 3 months, abdominal, thoracic, cranial or eye surgery in the last 3 months, traumatic cardiopulmonary resuscitation, acute aortic dissection, peptic ulcer, existing pregnancy, arterial hypertension (>175/120 mmHg) non-responsive to habitual therapy. For patient age, the concept of ‘functional’ age was used, which means that patients above the upper limit (>70 years) were included if they presented favorable clinical and psychological conditions. In fact, 56 patients in our study group were older than 70 years.

2.2. Diagnosis of acute myocardial infarction
Diagnosis of acute myocardial infarction was made if the patient demonstrated any two of the following: (1) typical chest pain with ischemic characteristics between 20 min and 6 h; (2) persistence of segment ST elevation >1.5 mm in at least two contiguous leads of the 12-lead electrocardiogram after the administration of sublingual isosorbide dinitrate; or (3) elevation of serum levels of creatine kinase MB fraction above 20 IU/l.

2.3. Treatment regimen
All patients underwent thrombolytic therapy within 6 h of the onset of symptoms, with the exception of 10 patients treated in the last year, who were treated between 6 and 12 h. Thrombolytic therapy consisted of intravenous streptokinase administered as 750 000 U for 15 min (n=502 patients) or as 1 500 000 U for 30–60 min (n=88 patients). Patients received different doses of steptokinase according to treatment protocols that were in operation at the institution at the time they entered the study [10,11]. To avoid any bias, the dose of streptokinase was analyzed in this study as a continuous variable with consideration of the units of drug infused per kilogram of weight.

All patients received standard medical therapy in accordance with conventional guidelines.

2.4. Cardiac catheterization technique
Coronary arteriography was recommended to all patients, preferentially on the third day after acute myocardial infarction. The procedure was performed on 528 (89.5%) of the 590 patients at 3.0±2.7 days after myocardial infarction. Thirty-two (5%) of the 590 patients died before coronary arteriography could be performed. The remaining 30 patients either refused or had unfavorable conditions for the procedure. Visual analysis of the films was performed by a single observer. The left and right coronary systems were evaluated in several projections, including cranium-caudal angulations. The status of the infarct-related artery was classified according to the angiographic flow criteria of the Thrombolysis in Myocardial Infarction (TIMI) Study Group [12], and the coronary collateral flow was classified according to Schwartz's proposition [13]. The left ventricular systolic function was evaluated by contrast ventriculography in right anterior oblique view at 30° using customized computer software developed at the Heart Institute. The ejection fraction measurement was based on the area–length, using methodology tested in previous reports [14,15]. The left ventricle was divided into 100 chords and the centerline method was used to measure left ventricle shortening — the results on the global and regional shortening are shown in the S.D. of the normal mean. These analyses were also performed by a single observer.

2.5. Clinical subsets
Patients were classified according to the presence or absence of peripheral hypoperfusion (i.e. hypotension, tachycardia, confusion, cyanosis and oliguria) and pulmonary congestion (i.e. pulmonary rales and abnormal chest roentgenogram). Parallel hemodynamic subsets were developed according to clinical findings and subgrouped according to the modified Forrester classification [16]. Subset I included patients without either pulmonary congestion or peripheral hypoperfusion; subset IIa, patients with asymptomatic pulmonary congestion without peripheral hypoperfusion; subset IIb, patients with symptomatic pulmonary congestion without peripheral hypoperfusion; subset III, patients with peripheral hypoperfusion without pulmonary congestion; and subset IV, patients with both pulmonary congestion and peripheral hypoperfusion.

2.6. Data analysis
Short- and long-term analyses were performed. For analysis of the short-term follow-up at 14 days after myocardial infarction, patient data were grouped according to the clinical subsets, and the corresponding survival rates were compared using the {chi}2 test. In this sequence, a step-wise multiple regression analysis was performed with survival as the dependent variable. Table 1 shows the dependent variables analyzed.

Different methods were combined to analyze long-term follow-up data, available as long as 10 years after myocardial infarction. For each method, long-term follow-up data was analyzed in the entire group of patients and also exclusively in patients who had survived the short-term follow-up period. The average long-term follow-up was 3.8 years in the total population and 4.2 years when patients who did not survive 14 days were excluded. Two Kaplan–Meyer curves were constructed for each of the clinical subsets: the first included patients who died during the short-term period, and the second excluded these patients. The log-rank test was used to compare differences in survival patterns between the groups. In the same sequence, two Cox proportional hazards regression models with all 19 variables listed in Table 1 were also brought about — also including and excluding patients who died during the short-term period.

All statistical analyses were performed using SYSTAT and BMDP software programs [17,18]. The confidence interval (CI) was set at 95% and differences were considered significant when P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
3.1. Characteristics of the population
Table 1 summarizes the characteristics of the study population (n=590) as well as the variables used in the regression analysis. The demographics and clinical characteristics of these patients encompass a sample of the spectrum of acute myocardial infarction patients who are eligible for thrombolytic therapy. A total of 58 (9.8%) patients died within 14 days of enrollment and 151 (25.6%) were dead at the end of the 10-year follow-up. It is important to note that no patients were lost during the follow-up, which means that the long-term mortality data was obtained in 100% of the population.

3.2. Correlation between medical evaluation and short-term survival
There was a direct correlation between clinical subsets and short-term survival, with the highest rate for the patients in subset I. The rate of correlation declined according to the progression along the clinical subgroup classification (P<0.001) (Fig. 1). Multiple regression analysis with the 19 variables included in the model (see Table 1), demonstrated that lower clinical subset, less number of coronary arteries with >70% obstruction, younger age, longer interval between streptokinase infusion and coronary arteriography, absence of reinfarction, and higher global left ventricular ejection fraction had an independent, and significant correlation with survival (Table 2).


Figure 1
View larger version (7K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Fig. 1 Correlation between medical evaluation at hospital arrival and short-term (14-day) survival (P<0.001).

 


View this table:
[in this window]
[in a new window]

  		Table 2 Multiple regression analysis of short-term follow-up data in the total study population (n=590)a

 
3.3. Correlation between clinical subsets and survival in the long-term follow-up
The overall long-term survival rates at the end of the follow-up were 71±3.6% for subset I; 54.4±8.5% for subset IIa; 20.8±9.4% for subset IIb; 54.5±15% for subset III; and 0% for subset IV ({chi}2=111.25, P<0.001) (Fig. 2). By Cox regression analysis, lower clinical subset, younger age, higher global left ventricular ejection fraction, and smaller number of coronaries obstructed >70% correlated significantly and independently with long-term survival (Table 3).


Figure 2
View larger version (14K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Fig. 2 Correlation between medical evaluation at hospital arrival and long-term (up to 10 years) survival.

 


View this table:
[in this window]
[in a new window]

  		Table 3 Cox regression analysis of long-term follow-up data in the total study population (N=590)a

 
Long-term survival rates among patients who survived at least until the short-term, 14-day, follow-up were 74.3±3.7% for subset I, 65.3±8.9% for subset IIa, 34.6±14.7% for subset IIb, 100% for subset III, and 0% for subset IV ({chi}2=56, P<0.001). It is important to note that only six subset III patients — patients with isolated peripheral hypoperfusion without pulmonary congestion — survived to 14 days. By Cox multivariate regression analysis with the same 19 variables, lower clinical subset, younger age, higher left ventricular ejection fraction, and an absence of previous myocardial infarction correlated independently and significantly with survival (Table 4).


View this table:
[in this window]
[in a new window]

  		Table 4 Cox regression analysis of long-term follow-up data only in patients who survived the short-term follow-up period (N=532)a

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
In our population of acute myocardial infarction patients, a highly representative sample of the general population of myocardial infarction patients who undergo thrombolysis, the prognosis of short-term and long-term survival was assessed according to clinical and laboratory in-hospital evaluations.

4.1. Effect of coronary thrombolysis on left ventricular function
Previous trials have used the preservation of left ventricular function as an important end point — which in turn, is also well-known to be prognostically important [15]. As with survival, improvement in global left ventricular function is related to the interval between the onset of pain and the beginning of thrombolytic therapy [19]. However, even global ejection fraction is not ideal as a measure of left ventricular function because hyperkinesis of un-involved myocardium may prevent the reduction that would result from akinesis of the involved muscle. Moreover, even the apparent benefit of early thrombolytic treatment would be partially masked by the ‘time-to-treatment paradox’ [20]. Indeed, according to this hypothesis, early reopening of the infarct-related artery would save a number of individuals with initial extensive myocardial damage who otherwise would have died. Therefore, the proportion of infarct survivors with poor left ventricular function would be increased.

4.2. Severity of heart failure on admission
Our study population was classified into predefined clinical subsets. The fundamental assumption of this classification is that depression of left ventricular function according to the Frank–Starling mechanism is the direct cause of the clinical manifestations of heart failure in acute myocardial infarction (i.e. increased left ventricular diastolic pressure results in pulmonary congestion and depressed cardiac output causes peripheral hypoperfusion [16,21]. Moreover, the severity of heart failure has been associated with delay to admission [22] and sustained monomorphic ventricular tachycardia [23].

More recently, the GUSTO-1 study [24], analyzing more than 40 000 patients subjected to thrombolytic treatment, showed an 85% incidence of patients arriving at hospital without clinical signs or symptoms of decompensation. In our study, the incidence was 83.9%. On the other hand, the incidence of congestive heart failure at hospital admittance was only 6% in the TAMI trials [25]. Regarding the incidence of cardiogenic shock, Col et al. [26] noted in a review of 94 trials involving thrombolytic agents, an average incidence of 5% (range 1–18%), among patients with acute myocardial infarction arriving at hospital. In the GUSTO-1 trial [24], 1% of the study population were in cardiogenic shock at admission. In our study, 3.6% of the patients were classified in subset IV by the time they arrived at hospital (Table 1).

One important modification in our classification, relative to the original by Forrester et al. [16], was the division of subset II into ‘a’ and ‘b’, according to the presence or absence of symptoms, respectively. By using this division, we were able to demonstrate that the presence of symptoms, in addition to the presence of pulmonary rales and chest X-ray alterations, did have prognostic significance (Figs. 1 and 2).

4.3. Short-term analysis
The results obtained, showing significant and independent correlations between short-term survival and a lower number of coronary arteries markedly obstructed, younger age, absence of reinfarction, and higher left ventricular ejection fraction, have been described previously [24,27–29]. The significant correlation between short-term survival and longer interval between the streptokinase infusion and the coronary angiography, probably represents the fact that higher risk patients are usually sent to the catheterization lab more quickly than more stable patients. Accordingly, we preferred to study our patients by means of coronary angiography on the third day after myocardial infarction; however, those patients in cardiogenic shock, for instance, were usually studied on an emergency basis.

In respect to the clinical classification used, Forrester et al. [16] in the pre-thrombolytic era, demonstrated a good correlation between clinical examination and invasive measurements. In their study, they demonstrated an 83% accuracy rate for clinical examination to predict hemodynamic abnormalities. Moreover, these investigators demonstrated similar in-hospital mortality rates in the clinical and hemodynamic subsets. In our study, we also observed an excellent correlation between the clinical subsets and prognosis (Fig. 1). The short-term survival rates observed in our clinical subgroups, 96.6, 83.3, 60 and 34.8% for I, IIa, IIb and IV, respectively, were very similar to survival rates observed in another study involving data from 1873 patients analyzed according to the Killip classification [30]. Rott et al. observed a 95% survival rate in patients classified as Killip I, 79% in those classified as Killip II, 65% in those classified as Killip III, and 33% in those classified as Killip IV.

Also, in our study, clinical examination upon hospital arrival demonstrated the best correlation with survival (P<0.001) among all 19 variables analyzed in a multivariate model (Table 2). This is in accordance with the data from the GUSTO-1 study [24], which showed a significant and independent correlation between Killip class at initial presentation and 30-day mortality.

4.4. Long-term analysis
There is little data available regarding the role of clinical examination upon hospital arrival on the long-term prognosis after myocardial infarction. Hosoda et al. [31] observed an excellent correlation between long-term survival at a mean follow-up of 2.9 years and either Killip's or Forrester's classification upon hospital admission, in patients with acute myocardial infarction subjected to emergency coronary arteriography. Of these, 25% were treated concomitantly with intracoronary thrombolysis and 15% were treated concomitantly with primary coronary angioplasty. Specifically, in patients treated with thrombolytics, the GISSI-2 study [32] showed a significant and independent correlation between 6-month mortality and ‘early left ventricular failure’, defined as Killip class greater than II on admission or the new appearance of symptoms and signs of left ventricular failure within 4 days of admission to the cardiac care unit. In our study, an excellent correlation between the clinical subsets obtained at hospital arrival and long-term follow-up, both for the total population as well as for only those patients who survived the short-term period, was demonstrated. Perhaps more importantly, by multivariate analysis, the clinical examination correlated significantly and independently with survival and mortality as well, regardless of whether data from patients with short-term deaths were excluded from the analysis.

4.5. Clinical implications
Despite the fact that bedside hemodynamic monitoring has become a helpful instrument for diagnosing and treating deranged cardiac function after myocardial infarction, clinical examination may still reveal meaningful information relevant to prognosis and therapy. The data presented in this study suggest that in patients with acute myocardial infarction, the clinical findings upon hospital presentation are powerful predictors of both short-term (14 days) and long-term (up to 10 years) survival. This is the first study, to our knowledge, that demonstrates that the association between short-term survival and the severity of heart failure at presentation is sustained in the long-term follow-up.

In addition, this study demonstrates the importance of the physical examination of patients with acute myocardial infarction, treated with streptokinase infusion upon hospital presentation, for the prognosis of short- and long-term survival. Furthermore, our findings coupled with data from other trials that have studied thrombolytic drugs [33,34], primary coronary angioplasty [35] and, more recently, pre-hospital thrombolysis [36], highlight the importance of early coronary reperfusion in myocardial infarction.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
The appropriate use of modern investigative procedures do not replace, but supplement careful clinical examination, which still remains the cornerstone of the appraisal of the patient with known cardiovascular disease.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

  1. Kennedy J.W, Martin G.Y, Davis K.B, et al. The Western Washington intravenous streptokinase in acute myocardial infarction randomized trial. Circulation (1988) 77:345–352.[Abstract/Free Full Text]
  2. Gruppo Italiano per lo Studio della Streptochinasi Nell-Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet (1986) 1:397–401.[CrossRef][Medline]
  3. ISIS-2 Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17 187 cases of suspected acute myocardial infarction: ISIS-2. Lancet (1988) 2:349–360.[Medline]
  4. Weaver W.D, Cerqueira M, Hallstrom A.P, et al. Pre-hospital initiated vs. hospital initiated thrombolytic therapy: the myocardial infarction triage and intervention trial. JAMA (1993) 270:1211–1216.[Abstract/Free Full Text]
  5. The International Study Group. In-hospital mortality and clinical course of 20 891 patients with suspected acute myocardial infarction randomized between alteplase and streptokinase with or without heparin. Lancet (1990) 336:71–79.[CrossRef][Web of Science][Medline]
  6. ISIS-3 (Third International Study of Infarct Survival) Collaborative Group. ISIS-3: a randomized comparison of streptokinase vs. tissue plasminogen activator vs. anistreplase and aspirin plus heparin vs. aspirin alone among 41 299 cases of suspected acute myocardial infarction. Lancet (1993) 339:753–770.[Web of Science]
  7. The GUSTO-1 Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Eng J Med (1993) 329:673–682.[Abstract/Free Full Text]
  8. Sanz G, Castaner A, Bietriu A, et al. Determinants of prognosis in survivors of myocardial infarction. N Eng J Med (1982) 306:1065–1070.[Abstract]
  9. Moss A.J, Decamilla J, Davis H, Bayer L. The early posthospital phase of myocardial infarction: prognostic stratification. Circulation (1976) 54:58–64.[Abstract/Free Full Text]
  10. Nicolau J.C, Pinto M.A.F.V, Nogueira P.R, Jacob J.L.B, Lorga A.M, Garzon S.A.C. Função ventricular esquerda na fase aguda de infartados submetidos aleatoriamente a 750 000 ou 1.5 milhão de unidades de estreptoquinase (Left ventricular function in the acute phase of infarcted patients randomized to 750 000 or 1.5 million units of streptokinase). Arq Bras Cardiol (1995) 65:91–95.[Medline]
  11. RAPT Investigators. Randomized trial of Ridogrel, a combined thromboxane A2 sinthase inhibitor and thromboxane A2/prostaglandin endoperoxide receptor antagonist, vs. aspirin as adjunct to thrombolysis in patients with acute myocardial infarction. Circulation (1994) 89:588–595.[Abstract/Free Full Text]
  12. Chesebro J.H, Knatterud G, Roberts R, et al. Thrombolysis In Myocardial Infarction (TIMI) Trial, Phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Circulation (1987) 76:142–154.[Abstract/Free Full Text]
  13. Schwartz H, Leiboff R.H, Bren G.B, et al. Temporal evolution of the human coronary collateral circulation after myocardial infarction. J Am Coll Cardiol (1984) 4:1088–1093.[Abstract]
  14. Nicolau J.C, Pinto M.A.F.V, Nogueira P.R, Lorga A.M, Jacob J.L.B, Garzon S.A.C. Preditores da sobrevida intra-hospitalar em pacientes infartados submetidos à terapêutica fibrinolítica (Predictors of in-hospital survival among infarcted patients submitted to fibrinolytic therapy). Arq Bras Cardiol (1993) 61:143–148.[Medline]
  15. Nicolau J.C, Garzon S.A.C, Pinto M.A.F.V, Nogueira P.R, Lorga A.M, Greco O.T. Acute myocardial infarction treated with intravenous streptokinase: 6-year follow-up. Int J Cardiol (1993) 38:253–262.[CrossRef][Web of Science][Medline]
  16. Forrester J.S, Diamond G.A, Swan H.J. Correlative classification of clinical and hemodynamic function after acute myocardial infarction. Am J Cardiol (1977) 39:137–145.[CrossRef][Web of Science][Medline]
  17. Wilkinson L. Statistics. In: Systat: the system for statistics—Wilkinson L, ed. (1990) Evanston, IL, USA: Systat Inc.
  18. Hintze J.L. Cox's proportional hazards regression. In: Solo statistics systems—Hintze J.L, ed. (1989) Los Angeles, CA, USA: BMDP.
  19. Sheehan F.H. Measurement of left ventricular function as an end point in trials of thrombolytic therapy. Cor Artery Dis (1990) 1:13–19.[Web of Science]
  20. Van de Werf F. Discrepancies between the effects of coronary reperfusion on survival and left ventricular function. Lancet (1989) 1:1367–1369.[Web of Science][Medline]
  21. Crexellis C, Chatterjee K, Forrester J.S, Dikshit K, Swan H.J. Optimal level of filling pressure in the left side of the heart in acute myocardial infarction. N Eng J Med (1973) 289:1263–1266.[Web of Science][Medline]
  22. Ottesen N.M, Kleber L, Jurgensen S, Torp-Pedersen C. Determinants of delay between symptoms and hospital admission in 5978 patients with acute myocardial infarction. The TRACE study group. Trandolapril cardiac evaluation. Eur Heart J (1996) 17:429–437.[Abstract/Free Full Text]
  23. Mont L, Cinca J, Blanch P, et al. Predisposing factors and prognostic value of sustained monomorphic ventricular tachycardia in the early phase of acute myocardial infarction. J Am Coll Cardiol (1996) 28:1670–1676.[Abstract]
  24. Lee K.L, Woodlief L.H, Topol E.J, et al. Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction: results from an international trial of 41 021 patients. Circulation (1995) 91:1659–1668.[Abstract/Free Full Text]
  25. O'Connor C.M, Hathaway W.R, Bates E.R, et al. Clinical characteristics and long-term outcome of patients in whom congestive heart failure develops after thrombolytic therapy for acute myocardial infarction: development of a predictive model. Am Heart J (1997) 133:663–673.[CrossRef][Web of Science][Medline]
  26. Col N.F, Gurwitz J.H, Alpert J.S, Goldberg R.J. Frequency of inclusion of patients with cardiogenic shock in trials of thrombolytic therapy. Am J Cardiol (1994) 73:149–157.[CrossRef][Web of Science][Medline]
  27. Topol E.J, Califf R.M, George B.S, Kereiakes D.J, Lee K.L. Insights derived from The Thrombolytics and Angioplasty In Myocardial Infarction (TAMI) Trials. J Am Coll Cardiol (1988) 12:24A–31A.[Medline]
  28. Muller D.W, Topol E.J, Ellis S.J, Sigmon K.M, Lee K, Califf R.M. Multivessel coronary artery disease: a key predictor of short-term prognosis after reperfusion therapy for acute myocardial infarction. Am Heart J (1991) 121:1042–1049.[CrossRef][Web of Science][Medline]
  29. Chaitman B.R, Thompson B, Wittry M.D, et al. The use of tissue-type-plasminogen activator for acute myocardial infarction in the elderly: results from Thrombolysis in Myocardial Infarction Phase I, open-label studies and the Thrombolysis in Myocardial Infarction Phase II Pilot Study. J Am Coll Cardiol (1989) 14:1159–1165.[Abstract]
  30. Rott D, Behar S, Gottlieb S, Boyko V, Hod H. Usefulness of the Killip classification for early risk stratification of patients with acute myocardial infarction in the 1990s compared with those treated in the 1980s. Israeli Thrombolytic Survey Group and the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group. Am J Cardiol (1997) 80:859–864.[CrossRef][Web of Science][Medline]
  31. Hosoda S, Kimata S, Tamura K, et al. Follow-up of 2733 Japanese patients with myocardial infarction. Jpn Circ J (1995) 59:121–129.[Medline]
  32. Volpi A, De Vita C, Franzosi M.G, et al. Determinants of 6-month mortality in survivors of myocardial infarction after thrombolysis. Results of the GISSI-2 data base. Circulation (1993) 88:416–429.[Abstract/Free Full Text]
  33. Fibrinolytic Therapy Trialists (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet (1994) 343:311–322.[CrossRef][Web of Science][Medline]
  34. Nicolau J.C, Nogueira P.R, Pinto M.A.F.V, Serrano C.V Jr., Garzon S.A.C. Early infarct artery collateral flow does not improve long-term survival following thrombolytic therapy for acute myocardial infarction. Am J Cardiol (1999) 83:21–26.[Web of Science][Medline]
  35. Weiss A.T, Leitersdorf I, Gotsman M.S, et al. Prevention of congestive heart failure by early, prehospital thrombolysis in acute myocardial infarction. Int J Cardiol (1998) 65:S43–S48.[CrossRef][Web of Science][Medline]
  36. Brodie B.R, Stuckey T.D, Wall T.C, et al. Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol (1998) 32:1312–1319.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (4)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Nicolau, J. C.
Right arrow Articles by Ramires, J. A.F.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Nicolau, J. C.
Right arrow Articles by Ramires, J. A.F.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?