European Journal of Heart Failure 2003 5(3):291-294; doi:10.1016/S1388-9842(02)00252-0
© 2002 European Society of Cardiology
The prognostic importance of heart failure and age in patients treated with primary angioplasty
Jose P.S. Henriques,
Felix Zijlstra*,
Menko-Jan de Boer,
Arnoud W.J. van't Hof,
A.T. Marcel Gosselink,
Jan-Henk E. Dambrink,
Harry Suryapranata and
Jan C.A. Hoorntje
Department of Cardiology, Isala Klinieken, Locatie Weezenlanden Groot Wezenland 20, 8011 JW Zwolle, The Netherlands
* Corresponding author. Tel.: +31-38-4242-374; fax: +31-38-4243-222. E-mail address: f.zijlstra{at}diagram-zwolle.nl
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Abstract
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Background: Effective risk stratification is essential in the management
of patients with acute myocardial infarction. Available models
have not yet been studied and validated in patients treated
with primary angioplasty for acute myocardial infarction.
Methods: The prognostic value of heart failure defined by Killip class and age upon admission and the impact of success and failure of the angioplasty procedure was studied in 1702 consecutive patients treated with primary angioplasty.
Findings: The combination of Killip class and age is a strong predictor of 30-day mortality and categorizes patients in subgroups with 30-day mortality risk ranging from 0.5 to 70%. Angioplasty failure results in a high 30-day mortality, in particular in patients with Killip class 
II and/or age 70 years. A large majority of patients (72%), characterized by Killip class I and age <70 years, can be identified with a 0.5% risk of death at 30 days.
Interpretation: The presence of heart failure (Killip class) and age predicts 30-day mortality in patients on their way to the catheterization laboratory for primary angioplasty. This simple and effective early risk stratification, in combination with success and failure of the primary angioplasty, can be used to direct subsequent patient management.
Key Words: Primary angioplasty • Myocardial infarction • Risk stratification
Received July 25, 2002; Revised October 17, 2002; Accepted December 2, 2002
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1. Introduction
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The short and medium term prognosis of patients with acute myocardial
infarction has been investigated extensively, and the identification
of factors that can be used to predict clinical outcome has
been a challenge since the late 1960s
[1–
8]. The introduction
of effective treatments into clinical practice has made a risk
assessment for individual patients even more important. As the
efficacy of therapeutic intervention in acute myocardial infarction
is time dependent, the risk profile of every single patient
should be available immediately when the patient enters the
medical care system. Low risk patients may be candidates for
admission to a step-down unit instead of a coronary care unit
and can often be discharged from the hospital after a few days
[4,
9]. Early identification of high-risk patients allows the
investigation and implementation of adjunctive measures to limit
myocardial damage and improve prognosis. In patients with acute
ST elevation myocardial infarction treated with thrombolysis,
the following factors: hemodynamics, age, infarct location,
a history of diabetes, hypertension or angina and time to reperfusion
therapy, all have an independent influence on clinical outcome
[4–
6]. This makes an algorithm to predict outcome in thrombolysis
patients somewhat more complex, although several simple and
practical proposals have been validated
[10,
11]. However, a
similar analysis for patients treated with primary angioplasty
has not yet been published. Analysis of the PCAT data
[12],
has shown that in patients treated with primary angioplasty
for acute ST elevation myocardial infarction, hemodynamics at
admission and age, are the only two clinical baseline characteristics
independently associated with 30-day mortality in multivariate
analysis
[13]. Therefore, we sought to investigate the predictive
value of the presence of heart failure, using the Killip classification
[1] and age, for early clinical risk stratification in 1702
consecutive patients treated with primary angioplasty for acute
ST elevation myocardial infarction.
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2. Methods
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All patients treated with primary angioplasty in our hospital
from 1994 to 2000, for acute ST elevation myocardial infarction,
presenting within 6 h after symptom onset, were included in
this analysis. Electrocardiographic criteria were ST segment
elevation of
1 mm in two or more contiguous leads. Baseline
clinical data, including Killip class were recorded immediately
upon admission in a case record form, before angiography and
angioplasty, and all data were entered into a dedicated database.
Medication at presentation was not recorded. The primary aim
of the risk stratification was the prediction of death from
any cause within 30 days after the acute event. No patient was
lost to follow-up.
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3. Results
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From 1994 to 2000, 1792 patients were admitted to our hospital
for acute myocardial infarction, of these 1702 (95%) patients
presented within 6 h of symptom onset and were treated with
primary angioplasty for acute ST elevation myocardial infarction.
Ages ranged from 27 to 91 years, with a mean (±S.D.)
of 60 (±12) years. Eighty percent of the patients were
male, 51% had an anterior wall infarct location, 12% had a previous
myocardial infarction, 8% had a history of diabetes, 52% had
an ischemic time from symptom-onset to presentation of <3
h, and 48% had an ischemic time between 3 and 6 h. Absence or
presence of pre infarction angina was documented in 1088 patients.
Pre infarction angina was defined as at least one episode of
chest pain in the 72 h before myocardial infarction. Four hundred
and forty two patients had pre infarction angina and 646 patients
no pre infarction angina, mortality was not different in both
groups, (1.6% vs. 1.4%, respectively,
P=0.80). The use of glycoprotein
(GP) IIb–IIIa inhibitors was documented in 544 patients.
In patients treated with GP IIb–IIIa inhibitors (
N=153)
mortality was not different compared with patients not treated
with GP IIb–IIIa inhibitors (
N=391), (1.3% vs. 2.3%, respectively,
P=0.74).
The relationship between Killip class and 30-day mortality is shown in Table 1 and the relationship between age and 30-day mortality is shown in Table 2. To study their independent value we performed multivariate analysis with a logistic regression analysis model with variables that were associated with higher mortality in the univariate analysis: Age 70 years, Killip class 2, anterior location of myocardial infarction, blood pressure at entry <100 mmHg (Table 3). Killip class 2 and age 70 years were the strongest predictors for 30-day mortality. Combining the information from these two parameters, a large group of patients can be identified with Killip class I and age <70 years: 1229 of 1702 patients (72%), with a very low risk (0.5%) of 30-day mortality. Patients with Killip class I and age >70 years have an intermediate risk with a 3.5% 30-day mortality, and patients with Killip class II have a 11% 30-day mortality, details are shown in Fig. 1. The primary angioplasty procedure was successful in restoring patency of the infarct related artery in 1612 of 1702 patients (94.7%), and failed in 90 of 1702 patients (5.3%). The prognostic information of Killip class and age showed a similar pattern in these two groups, although failed angioplasty resulted in high 30-day mortality rates, see Fig. 2a and b.
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Table 1 Killip class at presentation and 30-day mortality in 1702 patients treated with primary angioplasty for acute myocardial infarction
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Table 2 Age and 30-day mortality in 1702 patients treated with primary angioplasty for acute myocardial infarction
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Table 3 Clinical variables as risk factors of 30-day mortality in 1702 patients treated with primary angioplasty for acute myocardial infarction
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Fig. 2 (a) Relation between Killip class, age and 30-day mortality: the impact of success and failure of the primary angioplasty procedure. (b) Relation between Killip class, age and 30-day mortality: the impact of success and failure of the primary angioplasty procedure.
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4. Discussion
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The major finding from this study is that, based on Killip class
and age, a clinically meaningful acute risk stratification can
be performed in patients on their way to the catheterization
laboratory to undergo angioplasty for acute ST segment elevation
myocardial infarction. A large group of patients can be identified
with a very low 30-day mortality risk. Provided that the angioplasty
procedure is successful, they can be managed in a similar way
to patients treated with angioplasty for stable and unstable
angina, in a step-down unit or medium care facility, and they
are candidates for early discharge from the hospital and out-patient
rehabilitation. By identifying the patients at intermediate
or high risk early in their hospital course, coronary care or
intensive care beds can be used selectively for the patients
who really need them, and it allows the early consideration
of additional therapeutic measures to improve clinical outcome.
Based on Killip class, age and primary angioplasty procedural
success or failure, appropriate patient management is facilitated.
Previous attempts to risk stratify patients with acute myocardial infarction have mainly be done in patients treated with thrombolytic therapy and most have used multiple clinical factors [4–8]. For instance, in the GUSTO one trial, 16 factors were associated with 30-day mortality [5]. However, although the use of many factors may increase prognostic accuracy, it seems likely that this confuses rather than helps practicing physicians. The GISSI study group [8], the TIMI study group [6], the InTime II study group [10] and the NRMI study group [11] have all published simple and more or less practical assessments of risk of short term (in-hospital or 30-day) mortality. In the NRMI cohort of primary angioplasty patients, the TIMI risk score developed in thrombolysis patients performed in a similar way in the angioplasty patients to patients treated with thrombolysis [11]. Although the TIMI risk score gives points for nine items, most weight is given to hemodynamics and age [11]. An InTime II substudy calculated a risk index based only on heart rate, systolic blood pressure and age [10]. However, the major difference of all these studies and the findings from this study is the accurate identification of a large majority of patients with a very low risk, whereas the previous studies could only identify a minority of low risk patients with acute myocardial infarction, limiting the practical implications.
A pooled analysis of three trials of the PAMI study group has been performed to study the predictive value of the Killip classification [14]. Class IV patients were excluded. The analysis showed a clear relationship between in-hospital and 6 month mortality with Killip classes I, II and III, and reconfirmed the association between Killip class and many other clinical variables, such as age, history of diabetes, blood pressure, heart rate, left ventricular ejection fraction, peak creatine phosphokinase, use of intra-aortic balloon counter pulsation, incidence of renal failure, major arrhythmias and major bleeding. In their multivariate model to predict mortality, left ventricular ejection fraction played a prominent role and therefore this algorithm cannot be applied upon presentation.
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5. Study limitations
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Patients who presented more than 6 h after symptom onset were
excluded from this analysis, as these patients form a heterogeneous
population, with different clinical characteristics
[13,
15].
The impact of the use of beta-blockers and aspirin before admission
could not be studied, since we did not record medication at
presentation. However, previous investigations have shown that
less than 10% of the patients with acute myocardial infarction
in our area are using beta-blockers or aspirin before acute
myocardial infarction. Therefore, it seems unlikely that this
may have influenced our results. Treatment with GP IIb–IIIa
inhibitors only became established towards the end of the study
period. It was documented in only 544 patients and was started
after angioplasty and at the operators’ discretion. Therefore,
the possibility to study the impact of these agents was limited.
Although this is a post hoc analysis, all data used in this
study were gathered prospectively, and the residents who actually
filled in the case record forms, did so as part of routine clinical
practice. The 1702 patients described in this study come from
a single high volume interventional cardiology department with
a catheterization laboratory and coronary care unit staff dedicated
to the task of performing primary angioplasty 24 h a day, 7
days a week. This will certainly have played a role in the low
mortality rates in most subgroups of patients
[16,
17].
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6. Conclusions
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Based on Killip class and age, and procedural success or failure,
patients treated with primary angioplasty for acute myocardial
infarction can be risk stratified in a simple, effective and
accurate way. This information can be used to facilitate further
management. In the many low risk patients, reductions in hospital
stay and costs are possible, and in patients at intermediate
or high risk, early consideration of additional therapeutic
measures may result in improved clinical outcome.
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References
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Abstract
1. Introduction