Very early risk stratification after thrombolytic therapy with a bedside myoglobin assay and the 12-lead electrocardiogram

被引:24
作者
de Lemos, JA
Antman, EM
Giugliano, RP
Morrow, DA
McCabe, CH
Charlesworth, A
Schröder, R
Braunwald, E
机构
[1] Brigham & Womens Hosp, Div Cardiovasc Med, Boston, MA 02115 USA
[2] Nottingham Clin Trial Data Ctr, Nottingham, England
[3] Univ Klinikum Benjamin Franklin, Berlin, Germany
关键词
D O I
10.1067/mhj.2000.109216
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background Available clinical criteria to estimate prognosis in patients with evolving ST-segment elevation myocardial infarction do not consider the impact of reperfusion therapy and do not incorporate measurement of baseline levels of cardiac serum markers. We evaluated the combination of a baseline myoglobin assay and early (60- to 90-minute) ST resolution for risk stratification after ST-segment elevation myocardial infarction. Methods In a prospective substudy of the Intravenous nPA for Treatment of Infarcting Myocardium Early-it (InTIME-II) trial carried out in 2079 patients, a rapid qualitative assay for myoglobin was performed immediately before thrombolysis. Serial 12-lead electrocardiograms were performed at baseline and 60 to 90 minutes after thrombolysis. ST resolution was categorized as complete (greater than or equal to 70%), partial (30% to <70%), or none (<30%). Results Mortality rate at 30 days was 3.3% in the 905 patients with a negative baseline myoglobin assay versus 8.9% in the 527 patients with a positive assay (P < .0001). Mortality rate was lowest (2.4%) among the 614 patients with complete ST resolution, intermediate (4.9%) among the 512 patients with partial ST resolution, and highest (8.1%) among the 540 patients with no ST resolution (P < .0001 for trend). In a logistic regression model incorporating other baseline predictors of 30-day mortality rate, both a positive myoglobin assay (relative risk 1.98, 95% confidence interval 1.00-3.90) and ST resolution <70% (relative risk 2.86, 95% confidence interval 1.22-6.69) were independently associated with increased mortality rate. At 30 days, mortality rate was 0.4% among patients with a negative myoglobin assay and complete ST resolution, 4.8% among patients with either a positive myoglobin assay or ST resolution 170%, and 9.6% among those with both a positive myoglobin ratio and ST resolution <70% (P < .001 for trend). Conclusions Within 90 minutes after administering thrombolytic therapy for acute myocardial infarction, clinicians can determine the risk for death at the patient's bedside with a hand-held myoglobin assay and 2 serial 12-lead electrocardiograms. A strategy using these 2 simple, rapid, and inexpensive tests may facilitate triage after thrombolytic therapy.
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页码:373 / 378
页数:6
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