European Heart Association Journal 2007 April 2007.5.11. Emergency Medicine R3 김현진

Introduction In 2000, The Joint European Society of Cardiology/American College of Cardiology (ESC/ACC) Committee for the redefinition of myocardial infarction suggested that any amount of necrosis resulting from ischaemia should be diagnosed as a myocardial infarction Unstable angina -> MI Higher level of troponin : associated with more severe prognosis

The aim of this study To describe MI patients’ in-hospital and long-term management and their clinical outcomes and to identify independent predictors of death

Methods : Inclusion criteria 18 years 이상 hospitalized for a myocardial infarction [defined as a rise in cardiac enzyme concentrations (TN- I and/or T, and/or CK-MB) according to the local hospital’s standard in the first 24 h] And have the diagnosis of myocardial infarction confirmed at discharge

Results : study population OPERA study 56 centres in France October 2002 ~ September 2003 2151 consecutive patients (76.0% men) with myocardial infarction

Results : study population Almost half (48.1%) new or old Q-wave myocardial infarction One-fifth (19.8%) left-ventricular dysfunction (LVEF 40%) The median time between symptom onset and arrival at hospital : 6 h shorter with STEMI vs. with NSTEMI (4 vs. 7 h, P ,0.0001). The mean length of hospitalization 9.0+7.7 days

Results : In-hospital treatments

Results : Treatments at 12 months following discharge

Results : In-hospital and post-discharge outcomes

Results : One year Kaplan-Meier survival curves STEMI vs. NSTEMI

Results : Independent predictors of in-hospital mortality

Results : Independent predictors of 1 year post-discharge mortality

Discussion The results of our study patients with STEMI, who benefit most from reperfusion therapy (fibrinolytic drug or primary PCI) soon after the onset of symptoms, still delay presentation to hospital by 4 h The rates of the use of aspirin at admission lower (87 vs. 91%) than those reported in the Global Registry of Acute Coronary Events (GRACE) increased to 91% for STEMI and 86% for NSTEMI by the time of discharge

Discussion Statin the strongest predictor of in-hospital death less than half : given a statin at admission 80% : one at hospital discharge 83% : statin at 1 year follow-up. the strongest predictor of in-hospital death untreated dyslipidaemia advanced age, diabetes, and low blood pressure on admission independent predictors of in-hospital death

Discussion the strongest independent predictor of 1 year mortality history of heart failure, advanced age, untreated dyslipidaemia, diabetes, increased heart rate, low blood pressure on admission Treatment with statin associated with a lower risk of in-hospital and 1 year death compared with no dyslipidaemia also for the STEMI subgroup Support to early and continuing treatment

Are patients with STEMI very different from those with NSTEMI? The same pathophysiological process The same treatments to prevent plaque rupture In this study, the presence of ST-elevation drives the decision to proceed to rapid reperfusion therapy prescription at discharge of cardiac medications favored patients with STEMI The baseline characteristics of the two subgroups differed NSTEMI patients being older and at higher risk of recurrent ischemic events also at greater risk of death following discharge

Are patients with STEMI very different from those with NSTEMI? The cumulative in-hospital to 1 year post-discharge mortality did not differ between the two groups The annual rates of angioplasty and revascularization & the strongest predictors of death similar between STEMI and NSTEMI These findings support the new ESC/ACC definition of myocardial infarction, which combines STEMI with NSTE-ACS and elevated troponin

Conclusions patients with NSTEMI and STEMI have comparable in-hospital and long-term prognoses also have similar independent correlates of adverse outcome These findings support the new ESC/ACC definition of myocardial infarction, which combines STEMI with NSTE-ACS and elevated troponin STEMI and NSTEMI patients are treated differently in terms of coronary reperfusion but more surprisingly also in terms of secondary prevention

Conclusions Compared with STEMI, patients with NSTEMI appear to be undertreated after discharge from hospital despite having a higher risk profile The common definition and similar prognosis of patients with STEMI or NSTEMI should lead to more similar secondary prevention therapies to avoid recurrent ischemic events