Hathaway W R, Peterson E D, Wagner G S, Granger C B, Zabel K M, Pieper K S, Clark K A, Woodlief L H, Califf R M
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
JAMA. 1998 Feb 4;279(5):387-91. doi: 10.1001/jama.279.5.387.
Early risk stratification of patients with myocardial infarction is critical to determine optimum treatment strategies and enhance outcomes, but knowledge of the prognostic importance of the initial electrocardiogram (ECG) is limited.
To assess the independent value of the initial ECG for short-term risk stratification after acute myocardial infarction.
Retrospective analysis of the Global Utilization of Streptokinase and t-PA (alteplase) for Occluded Coronary Arteries (GUSTO-I) clinical trial database.
A total of 1081 hospitals in 15 countries.
From the 41 021 patients enrolled in the overall study, we selected those who presented within 6 hours of chest pain onset with ST-segment elevation and no confounding factors (paced rhythms, ventricular rhythms, or left bundle-branch block) on the ECG performed before thrombolysis was administered (n=34 166).
Ability of initial ECG to predict all-cause mortality at 30 days.
Most ECG variables were associated with 30-day mortality in a univariable analysis. In a multivariable analysis combining the initial ECG variables and clinical predictors of mortality, the sum of the absolute ST-segment deviation (both ST elevation and ST depression: odds ratio [OR], 1.53; 95% confidence interval [CI], 1.38-1.69), ECG, heart rate (OR, 1.49; 95% CI, 1.41-1.59), QRS duration (for anterior infarct: OR, 1.55; 95% CI, 1.43-1.68), and ECG evidence of prior infarction (for new inferior infarct: OR, 2.47; 95% CI, 2.02-3.00) were the strongest ECG predictors of mortality. A nomogram based on the multivariable model produced excellent discrimination of 30-day mortality (C-index, 0.830).
In patients presenting with myocardial infarction accompanied by ST-segment elevation, components of the initial ECG help predict 30-day mortality. This information should be valuable in early risk stratification, when the opportunity to reduce mortality is greatest, and may help in assessing outcomes adjusted for patient risk.
心肌梗死患者的早期风险分层对于确定最佳治疗策略和改善预后至关重要，但对于初始心电图（ECG）预后重要性的认识有限。
评估急性心肌梗死后初始心电图对短期风险分层的独立价值。
对冠状动脉闭塞性疾病链激酶和t-PA（阿替普酶）全球应用（GUSTO-I）临床试验数据库进行回顾性分析。
15个国家的共1081家医院。
在总共纳入的41021例患者中，我们选择了那些在胸痛发作6小时内出现ST段抬高且在溶栓治疗前进行的心电图无混杂因素（起搏心律、室性心律或左束支传导阻滞）的患者（n = 34166）。
初始心电图预测30天全因死亡率的能力。
在单变量分析中，大多数心电图变量与30天死亡率相关。在将初始心电图变量和死亡率的临床预测因素相结合的多变量分析中，绝对ST段偏移总和（ST段抬高和ST段压低：比值比[OR]，1.53；95%置信区间[CI]，1.38 - 1.69）、心电图心率（OR，1.49；95%CI，1.41 - 1.59）、QRS波时限（前壁梗死：OR，1.55；95%CI，1.43 - 1.68）以及既往梗死的心电图证据（新发下壁梗死：OR，2.47；95%CI，2.02 - 3.00）是死亡率最强的心电图预测因素。基于多变量模型的列线图对30天死亡率具有出色的辨别能力（C指数，0.830）。
在伴有ST段抬高的心肌梗死患者中，初始心电图的各项指标有助于预测30天死亡率。在降低死亡率机会最大的早期风险分层中，该信息应具有重要价值，并且可能有助于评估根据患者风险调整后的预后。
