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Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: Implications for early discharge
General Cardiology
Study Question: The aim of this study was to create a practical score for risk stratification in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty and to assess the feasibility of early discharge in low-risk patients. Methods: The study population comprised a total of 1791 patients with STEMI treated by primary angioplasty between August 1994 and October 2001. A prognostic score was built according to 30-day mortality rates in those patients undergoing primary angioplasty for STEMI. Results: For the identified low-risk patients without any contraindication to early discharge, investigators estimated and compared the costs of conventional care (prolonged 24-h hospitalization) with the costs of shifting the care from inpatient to outpatient setting (early discharge) between 48 and 72 h. Independent predictors of 30-day mortality included in the score were age, anterior infarction, Killip class, ischemic time, postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow, and multivessel disease. This score was able to identify a large cohort (73.4%) of low-risk (score ⱕ3) patients, with a good discriminatory capacity (c statistic⫽0.907). The mortality rate was 0.1% at 2 days and 0.2% between 2 and 10 days in patients with a score ⱕ3. The incremental cost-effectiveness ratio for late discharge in low-risk patients was estimated at €1949.33. Therefore, this policy would save one life per 1097 low-risk patients, at additional are cost of €194,933.33, in comparison with an early discharge policy. Conclusions: The researchers concluded that the developed risk score is a practical and useful index for risk stratification after primary angioplasty for STEMI, with a significant impact on clinical decision making and the related costs. It reliably identifies a large group of patients at very low risk, who may safely be discharged early after primary angioplasty. Perspective: The study shows that a policy of early discharge (48 h after primary angioplasty) could be applied safely to a large group (⬎60%) of STEMI patients at a very low risk. These patients can be identified by the use of a simple bedside clinical risk score. A more widespread application of early discharge would result in a considerable reduction in costs for the treatment of patients with STEMI. DM
Abstracts A Validated Prediction Model for All Forms of Acute Coronary Syndrome: Estimating the Risk of 6-Aug Postdischarge Death in an International Registry Eagle KA, Lim MJ, Dabbous OH, et al. JAMA 2004;291:2727–33. Study Question: Accurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy. The objective of this study was to develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS. Methods: The investigators used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months’ postdischarge. From 17,142 patients presenting with an ACS, and discharged alive, 15,007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients. The primary outcome measure was all-cause mortality during 6 months’ postdischarge. Results: The 6-month mortality rates were similar in the development (n⫽717; 4.8%) and validation cohorts (n⫽331; 4.7%). The risk-prediction tool for all forms of ACS identified nine variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram (ECG), and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively. Conclusions: Investigators concluded that the GRACE 6-month postdischarge prediction model is a simple; robust tool for predicting mortality in patients with ACS. Perspective: Investigators used a large multinational registry and developed and validated a simple bedside prediction tool that can be used to estimate a patient’s postdischarge risk of 6-month mortality in all forms of ACS, regardless of their initial ECG or biomarker results. The major strength of this particular tool is that it focuses on the clinically relevant and objective end point of death as opposed to several prior risk-stratification tools, including several subjective end points such as recurrent ischemia or need for urgent revascularization. The current tool will be objective, simple to use and highly relevant to clinical practice. DM
Enhancing Quality of Care for Acute Myocardial Infarction: Shifting the Focus of Improvement From Key Indicators to Process of Care and Tool Use: The American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw Expansion
Prognostic Assessment of Patients With Acute Myocardial Infarction Treated With Primary Angioplasty: Implications for Early Discharge
Mehta RH, Montoye CK, Faulet J, et al. J Am Coll Cardiol 2004; 43:2166 –73.
De Luca G, Suryapranata H, van’t Hof AWJ, et al. Circulation 2004;109:2737– 43.
Study Question: This project posed the question: If by focusing on process changes and tool use rather than key indica-
ACC CURRENT JOURNAL REVIEW Aug 2004
9
Study Question: The aim of this study was to create a practical score for risk stratification in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty and to assess the feasibility of early discharge in low-risk patients. Methods: The study population comprised a total of 1791 patients with STEMI treated by primary angioplasty between August 1994 and October 2001. A prognostic score was built according to 30-day mortality rates in those patients undergoing primary angioplasty for STEMI. Results: For the identified low-risk patients without any contraindication to early discharge, investigators estimated and compared the costs of conventional care (prolonged 24-h hospitalization) with the costs of shifting the care from inpatient to outpatient setting (early discharge) between 48 and 72 h. Independent predictors of 30-day mortality included in the score were age, anterior infarction, Killip class, ischemic time, postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow, and multivessel disease. This score was able to identify a large cohort (73.4%) of low-risk (score ⱕ3) patients, with a good discriminatory capacity (c statistic⫽0.907). The mortality rate was 0.1% at 2 days and 0.2% between 2 and 10 days in patients with a score ⱕ3. The incremental cost-effectiveness ratio for late discharge in low-risk patients was estimated at €1949.33. Therefore, this policy would save one life per 1097 low-risk patients, at additional are cost of €194,933.33, in comparison with an early discharge policy. Conclusions: The researchers concluded that the developed risk score is a practical and useful index for risk stratification after primary angioplasty for STEMI, with a significant impact on clinical decision making and the related costs. It reliably identifies a large group of patients at very low risk, who may safely be discharged early after primary angioplasty. Perspective: The study shows that a policy of early discharge (48 h after primary angioplasty) could be applied safely to a large group (⬎60%) of STEMI patients at a very low risk. These patients can be identified by the use of a simple bedside clinical risk score. A more widespread application of early discharge would result in a considerable reduction in costs for the treatment of patients with STEMI. DM
Abstracts A Validated Prediction Model for All Forms of Acute Coronary Syndrome: Estimating the Risk of 6-Aug Postdischarge Death in an International Registry Eagle KA, Lim MJ, Dabbous OH, et al. JAMA 2004;291:2727–33. Study Question: Accurate estimation of risk for untoward outcomes after patients have been hospitalized for an acute coronary syndrome (ACS) may help clinicians guide the type and intensity of therapy. The objective of this study was to develop a simple decision tool for bedside risk estimation of 6-month mortality in patients surviving admission for an ACS. Methods: The investigators used data from the Global Registry of Acute Coronary Events (GRACE) to develop and validate a multivariable stepwise regression model for death during 6 months’ postdischarge. From 17,142 patients presenting with an ACS, and discharged alive, 15,007 (87.5%) had complete 6-month follow-up and represented the development cohort for a model that was subsequently tested on a validation cohort of 7638 patients. The primary outcome measure was all-cause mortality during 6 months’ postdischarge. Results: The 6-month mortality rates were similar in the development (n⫽717; 4.8%) and validation cohorts (n⫽331; 4.7%). The risk-prediction tool for all forms of ACS identified nine variables predictive of 6-month mortality: older age, history of myocardial infarction, history of heart failure, increased pulse rate at presentation, lower systolic blood pressure at presentation, elevated initial serum creatinine level, elevated initial serum cardiac biomarker levels, ST-segment depression on presenting electrocardiogram (ECG), and not having a percutaneous coronary intervention performed in hospital. The c statistics for the development and validation cohorts were 0.81 and 0.75, respectively. Conclusions: Investigators concluded that the GRACE 6-month postdischarge prediction model is a simple; robust tool for predicting mortality in patients with ACS. Perspective: Investigators used a large multinational registry and developed and validated a simple bedside prediction tool that can be used to estimate a patient’s postdischarge risk of 6-month mortality in all forms of ACS, regardless of their initial ECG or biomarker results. The major strength of this particular tool is that it focuses on the clinically relevant and objective end point of death as opposed to several prior risk-stratification tools, including several subjective end points such as recurrent ischemia or need for urgent revascularization. The current tool will be objective, simple to use and highly relevant to clinical practice. DM
Enhancing Quality of Care for Acute Myocardial Infarction: Shifting the Focus of Improvement From Key Indicators to Process of Care and Tool Use: The American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw Expansion
Prognostic Assessment of Patients With Acute Myocardial Infarction Treated With Primary Angioplasty: Implications for Early Discharge
Mehta RH, Montoye CK, Faulet J, et al. J Am Coll Cardiol 2004; 43:2166 –73.
De Luca G, Suryapranata H, van’t Hof AWJ, et al. Circulation 2004;109:2737– 43.
Study Question: This project posed the question: If by focusing on process changes and tool use rather than key indica-
ACC CURRENT JOURNAL REVIEW Aug 2004
9