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Admission c-reactive protein levels and 30-day mortality in patients with acute myocardial infarction
General Cardiology
Methods: Consecutive patients (n⫽448, mean [⫾SD] age, 60⫾12 years) with acute myocardial infarction had their serum C-reactive protein levels measured within 12–24 hours of symptom onset and were divided into tertiles. Infarct size (by echocardiographic examination performed on day 2 or 3) and mortality at 30 days and subsequent cardiac events were determined for these tertiles. Results: Mortality at 30 days was higher with increasing C-reactive protein tertile (3%, 10% and 22% in low-, middle- and high-risk tertiles; p⫽0.02 for middle vs. lowest tertile and p⬍0.001 for highest vs. lowest tertile). Multivariate analysis identified C-reactive protein in the upper tertile as an independent-predictor of 30-day mortality (relative risk⫽3.0; 95% confidence interval [CI]: 1.3–7.2; p⫽0.01) and the development of heart failure (odds ratio⫽2.6; 95% CI: 1.5– 4.6; p⫽0.0006). In contrast, C-reactive protein levels were not associated with the development of postinfarction angina, recurrent myocardial infarction or the need for revascularization. Conclusion: Plasma C-reactive protein level obtained within 12–24 hours of symptoms onset is an independent marker of 30-day mortality and the development of heart failure in patients with acute myocardial infarction. Perspective: C-reactive protein, a marker of inflammation, appears to predict not only 30-day mortality but also the development of heart failure, suggesting a potential role of inflammation in left ventricular remodeling after acute myocardial infarction. RM
Abstracts Women’s Early Warning Symptoms of Acute Myocardial Infarction McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Barvin BJ. Circulation 2003;108:2619 –23. Study Question: What are the prodromal signs and symptoms of acute myocardial infarction in women? Methods: Women diagnosed with AMI from five sites (n⫽515) were surveyed 4 – 6 months after discharge using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey. This survey included a questionnaire with regards to their symptoms, comorbidities and demographic characteristics. Results: Women in this cohort were predominantly white (93%), high school educated (54.8%) and older (mean age, 66⫾12). Prodromal symptoms were reported in 95% of women with the most frequent prodromal symptoms experienced more than 1 month before AMI being unusual fatigue (70.7%), sleep disturbance (47.8%) and shortness of breath (42.1%). Chest discomfort was reported in only 29.7% more than a month before their AMI. The most frequent acute symptoms included shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%) with chest discomfort reported by only 43% of patients. Women had more acute (mean, 7.3⫾4.8; range, 0 –29) than prodromal (mean, 5.71⫾4.36; range, 0 –25) symptoms. These two scores were correlated (r⫽0.61, p⬍0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology. Conclusions: Most women have prodromal symptoms before AMI, but it is unknown whether prodromal symptoms are predictive of future events. Perspective: It is important to recognize that atypical presentation of AMI with shortness of breath, extreme fatigue and weakness, rather than typical chest discomfort, is not uncommon in women. The lack of healthy controls in this study makes it difficult to attribute the vague symptoms described a month before their AMI to be indicative of a future acute event, which is usually related to sudden plaque rupture. RM
Global Patterns of Use of Antithrombotic and Antiplatelet Therapies in Patients With Acute Coronary Syndromes: Insights from the Global Registry of Acute Coronary Events (GRACE) Budaj A, Brieger D, Steg G, et al. Am Heart J 2003;146:999 – 1006. Study Question: What are the patterns of use of antithrombotic and antiplatelet therapies across the globe in patients with the spectrum of acute coronary syndromes (ACS)? Methods: Patients with ACS (n⫽12,665) enrolled in the Global Registry of Acute Coronary Events (GRACE) had their data analyzed. Baseline characteristics, clinical presentation and medication use were compared in the different types of ACS, and regional differences in the use of antiplatelet and antithrombotic therapies were evaluated. Multivariable logistic regression was implemented to determine independent variables indicating the use of various hospital therapies. Results: The use of unfractionated heparin was higher than that for low–molecular-weight heparin (57% vs. 47%, p⬍0.0001). More than 90% of patients received aspirin in hospital, but approximately 13% were not discharged on aspirin. Overall, 30% of patients received thienopyridines (with percutaneous coronary intervention [PCI] in 79%). Of those who did not receive aspirin, 31% received thien-
Admission C-Reactive Protein Levels and 30-Day Mortality in Patients With Acute Myocardial Infarction Suleiman M, Aronson D, Reisner SA, et al. Am J Med 2003;115: 695–701. Study Question: What is the value of C-reactive protein levels in predicting the risk of subsequent cardiovascular events in patients with acute myocardial infarction?
ACC CURRENT JOURNAL REVIEW Mar 2004
9
Methods: Consecutive patients (n⫽448, mean [⫾SD] age, 60⫾12 years) with acute myocardial infarction had their serum C-reactive protein levels measured within 12–24 hours of symptom onset and were divided into tertiles. Infarct size (by echocardiographic examination performed on day 2 or 3) and mortality at 30 days and subsequent cardiac events were determined for these tertiles. Results: Mortality at 30 days was higher with increasing C-reactive protein tertile (3%, 10% and 22% in low-, middle- and high-risk tertiles; p⫽0.02 for middle vs. lowest tertile and p⬍0.001 for highest vs. lowest tertile). Multivariate analysis identified C-reactive protein in the upper tertile as an independent-predictor of 30-day mortality (relative risk⫽3.0; 95% confidence interval [CI]: 1.3–7.2; p⫽0.01) and the development of heart failure (odds ratio⫽2.6; 95% CI: 1.5– 4.6; p⫽0.0006). In contrast, C-reactive protein levels were not associated with the development of postinfarction angina, recurrent myocardial infarction or the need for revascularization. Conclusion: Plasma C-reactive protein level obtained within 12–24 hours of symptoms onset is an independent marker of 30-day mortality and the development of heart failure in patients with acute myocardial infarction. Perspective: C-reactive protein, a marker of inflammation, appears to predict not only 30-day mortality but also the development of heart failure, suggesting a potential role of inflammation in left ventricular remodeling after acute myocardial infarction. RM
Abstracts Women’s Early Warning Symptoms of Acute Myocardial Infarction McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Barvin BJ. Circulation 2003;108:2619 –23. Study Question: What are the prodromal signs and symptoms of acute myocardial infarction in women? Methods: Women diagnosed with AMI from five sites (n⫽515) were surveyed 4 – 6 months after discharge using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey. This survey included a questionnaire with regards to their symptoms, comorbidities and demographic characteristics. Results: Women in this cohort were predominantly white (93%), high school educated (54.8%) and older (mean age, 66⫾12). Prodromal symptoms were reported in 95% of women with the most frequent prodromal symptoms experienced more than 1 month before AMI being unusual fatigue (70.7%), sleep disturbance (47.8%) and shortness of breath (42.1%). Chest discomfort was reported in only 29.7% more than a month before their AMI. The most frequent acute symptoms included shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%) with chest discomfort reported by only 43% of patients. Women had more acute (mean, 7.3⫾4.8; range, 0 –29) than prodromal (mean, 5.71⫾4.36; range, 0 –25) symptoms. These two scores were correlated (r⫽0.61, p⬍0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology. Conclusions: Most women have prodromal symptoms before AMI, but it is unknown whether prodromal symptoms are predictive of future events. Perspective: It is important to recognize that atypical presentation of AMI with shortness of breath, extreme fatigue and weakness, rather than typical chest discomfort, is not uncommon in women. The lack of healthy controls in this study makes it difficult to attribute the vague symptoms described a month before their AMI to be indicative of a future acute event, which is usually related to sudden plaque rupture. RM
Global Patterns of Use of Antithrombotic and Antiplatelet Therapies in Patients With Acute Coronary Syndromes: Insights from the Global Registry of Acute Coronary Events (GRACE) Budaj A, Brieger D, Steg G, et al. Am Heart J 2003;146:999 – 1006. Study Question: What are the patterns of use of antithrombotic and antiplatelet therapies across the globe in patients with the spectrum of acute coronary syndromes (ACS)? Methods: Patients with ACS (n⫽12,665) enrolled in the Global Registry of Acute Coronary Events (GRACE) had their data analyzed. Baseline characteristics, clinical presentation and medication use were compared in the different types of ACS, and regional differences in the use of antiplatelet and antithrombotic therapies were evaluated. Multivariable logistic regression was implemented to determine independent variables indicating the use of various hospital therapies. Results: The use of unfractionated heparin was higher than that for low–molecular-weight heparin (57% vs. 47%, p⬍0.0001). More than 90% of patients received aspirin in hospital, but approximately 13% were not discharged on aspirin. Overall, 30% of patients received thienopyridines (with percutaneous coronary intervention [PCI] in 79%). Of those who did not receive aspirin, 31% received thien-
Admission C-Reactive Protein Levels and 30-Day Mortality in Patients With Acute Myocardial Infarction Suleiman M, Aronson D, Reisner SA, et al. Am J Med 2003;115: 695–701. Study Question: What is the value of C-reactive protein levels in predicting the risk of subsequent cardiovascular events in patients with acute myocardial infarction?
ACC CURRENT JOURNAL REVIEW Mar 2004
9