Volpi A, De Vita C, Franzosi M G, Geraci E, Maggioni A P, Mauri F, Negri E, Santoro E, Tavazzi L, Tognoni G
GISSI Coordinating Center, Istituto di Ricerche Farmacologiche Mario Negri, Milano, Italy.
Circulation. 1993 Aug;88(2):416-29. doi: 10.1161/01.cir.88.2.416.
Current knowledge of risk assessment in survivors of myocardial infarction is largely based on data gathered before the advent of thrombolysis. It must be determined whether and to what extent available information and proposed criteria of prognostication are applicable in the thrombolytic era.
We reassessed risk prediction in the 10,219 survivors of myocardial infarction with follow-up data available (ie, 98% of the total) who had been enrolled in the GISSI-2 trial, relying on a set of prespecified variables. The 3.5% 6-month all-cause mortality rate of these patients compared with the higher value of 4.6% found in the corresponding GISSI-1 cohort, originally allocated to streptokinase therapy, indicates a 24% reduction in postdischarge 6-month mortality. On multivariate analysis (Cox model), the following variables were predictors of 6-month all-cause mortality: ineligibility for exercise test for both cardiac (relative risk [RR], 3.30; 95% confidence interval [CI], 2.36-4.62) and noncardiac reasons (RR, 3.28; 95% CI, 2.23-4.72), early left ventricular failure (RR, 2.41; 95% CI, 1.87-3.09), echocardiographic evidence of recovery phase left ventricular dysfunction (RR, 2.30; 95% CI, 1.78-2.98), advanced (more than 70 years) age (RR, 1.81; 95% CI, 1.43-2.30), electrical instability (ie, frequent and/or complex ventricular arrhythmias) (RR, 1.70; 95% CI, 1.32-2.19), late left ventricular failure (RR, 1.54; 95% CI, 1.17-2.03), previous myocardial infarction (RR, 1.47; 95% CI, 1.14-1.89), and a history of treated hypertension (RR, 1.32; 95% CI, 1.05-1.65). Early post-myocardial infarction angina, a positive exercise test, female sex, history of angina, history of insulin-dependent diabetes, and anterior site of myocardial infarction were not risk predictors. On further multivariate analysis, performed on 8315 patients with the echocardiographic indicator of left ventricular dysfunction available, only previous myocardial infarction was not retained as an independent risk predictor.
A decline in 6-month mortality of myocardial infarction survivors, seen within 6 hours of symptom onset, has been observed in recent years. Ineligibility for exercise test, early left ventricular failure, and recovery-phase left ventricular dysfunction are the most powerful (RR, > 2) predictors of 6-month mortality among patients recovering from myocardial infarction after thrombolysis. Qualitative variables reflecting residual myocardial ischemia do not appear to be risk predictors. The lack of an independent adverse influence of early post-myocardial infarction angina on 6-month survival represents a major difference between this study and those of the prethrombolytic era.
目前关于心肌梗死幸存者风险评估的知识主要基于溶栓治疗出现之前收集的数据。必须确定现有信息和提议的预后标准在溶栓时代是否适用以及适用程度如何。
我们重新评估了10219名心肌梗死幸存者的风险预测情况，这些患者有随访数据（即占总数的98%），他们参加了GISSI - 2试验，依据一组预先设定的变量进行分析。这些患者6个月全因死亡率为3.5%，而在最初分配接受链激酶治疗的相应GISSI - 1队列中发现的较高值为4.6%，这表明出院后6个月死亡率降低了24%。在多变量分析（Cox模型）中，以下变量是6个月全因死亡率的预测因素：因心脏（相对风险[RR]，3.30；95%置信区间[CI]，2.36 - 4.62）和非心脏原因而不适合进行运动试验（RR，3.28；95% CI，2.23 - 4.72）、早期左心室衰竭（RR，2.41；95% CI，1.87 - 3.09）、超声心动图显示恢复阶段左心室功能障碍（RR，2.30；95% CI，1.78 - 2.98）、高龄（超过70岁）（RR，1.81；95% CI，1.43 - 2.30）、电不稳定（即频繁和/或复杂室性心律失常）（RR，1.70；95% CI，1.32 - 2.19）、晚期左心室衰竭（RR，1.54；95% CI，1.17 - 2.03）、既往心肌梗死（RR，1.47；95% CI，1.14 - 1.89）以及高血压治疗史（RR，1.32；95% CI，1.05 - 1.65）。心肌梗死后早期心绞痛、运动试验阳性、女性、心绞痛病史、胰岛素依赖型糖尿病病史以及心肌梗死前壁部位不是风险预测因素。在对8315名有左心室功能障碍超声心动图指标的患者进行的进一步多变量分析中，只有既往心肌梗死未被保留为独立风险预测因素。
近年来观察到心肌梗死幸存者在症状发作6小时内6个月死亡率有所下降。不适合进行运动试验、早期左心室衰竭和恢复阶段左心室功能障碍是溶栓后心肌梗死恢复患者中6个月死亡率最强的预测因素（RR，> 2）。反映残余心肌缺血的定性变量似乎不是风险预测因素。心肌梗死后早期心绞痛对6个月生存率缺乏独立的不良影响是本研究与溶栓前时代研究的主要差异。
