http://cardiologia.publicacionmedica.com/contenido/images/stemi_aha_2013.pdf

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.

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Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration.

Background Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk. Objective To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice. Methods A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001. Validation data sets included a subsequent cohort of 3972 patients enrolled in GRACE and 12 142 in the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial. Results The following 8 independent risk factors accounted for 89.9% of the prognostic information: age (odds ratio [OR], 1.7 per 10 years), Killip class (OR, 2.0 per class), systolic blood pressure (OR, 1.4 per 20-mm Hg decrease), ST-segment deviation (OR, 2.4), cardiac arrest during presentation (OR, 4.3), serum creatinine level (OR, 1.2 per 1-mg/dL [88.4-µmol/L] increase), positive initial cardiac enzyme findings (OR, 1.6), and heart rate (OR, 1.3 per 30-beat/min increase). The discrimination ability of the simplified model was excellent with c statistics of 0.83 in the derived database, 0.84 in the confirmation GRACE data set, and 0.79 in the GUSTO-IIb database. Conclusions Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.

https://www.outcomes-umassmed.org/grace/files/Granger_GRACE_Risk_Model_Archives.pdf

Predictors of hospital mortality in the global registry of acute coronary events.

1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction)

ContextEstimation of mortality risk in patients hospitalized with acute decompensated
heart failure (ADHF) may help clinicians guide care.ObjectiveTo develop a practical user-friendly bedside tool for risk stratification
for patients hospitalized with ADHF.Design, Setting, and PatientsThe Acute Decompensated Heart Failure National Registry (ADHERE) of
patients hospitalized with a primary diagnosis of ADHF in 263 hospitals in
the United States was queried with analysis of patient data to develop a risk
stratification model. The first 33 046 hospitalizations (derivation cohort;
October 2001-February 2003) were analyzed to develop the model and then the
validity of the model was prospectively tested using data from 32 229 subsequent
hospitalizations (validation cohort; March-July 2003). Patients had a mean
age of 72.5 years and 52% were female.Main Outcome MeasureVariables predicting mortality in ADHF.ResultsWhen the derivation and validation cohorts are combined, 37 772 (58%)
of 65 275 patient-records had coronary artery disease. Of a combined cohort
consisting of 52 164 patient-records, 23 910 (46%) had preserved left ventricular
systolic function. In-hospital mortality was similar in the derivation (4.2%)
and validation (4.0%) cohorts. Recursive partitioning of the derivation cohort
for 39 variables indicated that the best single predictor for mortality was
high admission levels of blood urea nitrogen (≥43 mg/dL [15.35 mmol/L])
followed by low admission systolic blood pressure (<115 mm Hg) and then
by high levels of serum creatinine (≥2.75 mg/dL [243.1 μmol/L]). A simple
risk tree identified patient groups with mortality ranging from 2.1% to 21.9%.
The odds ratio for mortality between patients identified as high and low risk
was 12.9 (95% confidence interval, 10.4-15.9) and similar results were seen
when this risk stratification was applied prospectively to the validation
cohort.ConclusionsThese results suggest that ADHF patients at low, intermediate, and high
risk for in-hospital mortality can be easily identified using vital sign and
laboratory data obtained on hospital admission. The ADHERE risk tree provides
clinicians with a validated, practical bedside tool for mortality risk stratification.

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Risk Stratification for In-Hospital Mortality in Acutely Decompensated Heart Failure: Classification and Regression Tree Analysis

Background The Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries (GUSTO-I) trial was designed to test whether thrombolytic strategies achieving more complete, early, sustained coronary artery patency would lead to further reductions in mortality in patients with acute myocardial infarction. An angiographic substudy within GUSTO-I provided a unique opportunity to examine the relation between mortality and degrees of patency among the regimens. 

Methods and Results Four thrombolytic strategies were compared in 41 021 patients in GUSTO-I: streptokinase with subcutaneous or intravenous heparin, accelerated tissue plasminogen activator (TPA) with intravenous heparin, and combination streptokinase plus TPA with intravenous heparin. Accelerated TPA was associated with lower 30-day mortality (6.3%) than the other strategies (7.2%, 7.4%, and 7.0%, respectively). Among the 1210 patients in the angiographic substudy randomized to angiography 90 minutes after starting treatment, there was improved patency, particularly Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, with accelerated TPA over the other regimens ( P <.0001). Coronary artery perfusion (TIMI grade 3) at 90 minutes was also a significant predictor of 30-day survival ( P <.01). To determine whether differences in mortality among the four strategies matched differences in 90-minute patency, a model was developed for predicting mortality differences in the main trial from the angiographic substudy. The model assumed that any differences in treatment effects on 30-day mortality were mediated through differences in 90-minute patency for the four treatments. The predicted rates were then compared with observed mortality rates of the remaining patients in the main trial for each treatment group. The predicted and observed 30-day mortality rates of the four treatments were streptokinase with subcutaneous heparin, 7.46% versus 7.28%; streptokinase with intravenous heparin, 7.26% versus 7.39%; accelerated TPA, 6.31% versus 6.37%; and streptokinase plus TPA, 6.98% versus 6.96%. The correlation between predicted and observed results was .97, and the proportion of squared error explained ( R 2) was .92. 

Conclusions The close relation between the predicted and observed 30-day mortality rates supports the concept that an important mechanism for improved survival with thrombolytic therapy is achievement of early, complete perfusion. The close match provides a strong biological explanation for the mortality differences seen in GUSTO-I and a sound rationale for the additional survival advantage of the accelerated TPA regimen. Irrespective of which treatment is used, early and complete restoration of infarct artery perfusion represents an essential goal of myocardial reperfusion therapy.

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Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion : importance of early and complete infarct artery reperfusion

Background —When a patient survives thrombolysis for acute myocardial infarction, little information from large studies exists from which to estimate prognosis during follow-up visits Methods and Results —Baseline, in-hospital, and later survival data were collected from 41 021 patients enrolled in Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries, a randomized trial of 4 thrombolytic-heparin regimens with standard aspirin and β-blockade Cox proportional hazards models were developed to predict 1-year survival in 30-day survivors (n=37 869) from baseline clinical and ECG factors and in-hospital factors; a combined model then was developed (C-index 0800) The model was simplified into a nomogram to predict individual outcomes (C-index 0754) Factors reflecting demographics (advanced age, lighter weight), larger infarctions (higher Killip class, lower blood pressure, faster heart rate, longer QRS duration), cardiac risk (smoking, hypertension, prior cerebrovascular disease), and arrhythmia were important predictors of death between 30 days and 1 year Black race was associated with a substantial increase in risk after considering other factors Revascularization was associated with reduced risk between 30 days and 1 year Conclusions —When evaluating a patient who has survived acute infarction treated with thrombolysis, clinicians can estimate the likelihood of survival from factors easily measured during admission Although many risk factors clearly relate to age, left ventricular dysfunction, or clinical instability, black race is an unexplained risk factor requiring further examination

Prediction of 1-Year Survival After Thrombolysis for Acute Myocardial Infarction in the Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries Trial

Background In the randomized Global Utilization of t-PA and Streptokinase for Occluded Coronary Arteries (GUSTO-I) trial, 41 021 patients received one of four thrombolytic regimens. Patients treated with accelerated tissue plasminogen activator (TPA) had a lower 30-day mortality rate (6.3%) than those treated with the other regimens (7.3%, combined streptokinase groups). Methods and Results Each patient who was alive at 30 days was sent a return postcard to ascertain vital status at 1 year. If the postcard was not returned, the patient (or an alternate specified at randomization) was contacted by telephone. A locator service was used in the United States for patients who could not be located by these methods. Final follow-up was 96% worldwide. One-year mortality rates remained in favor of accelerated TPA (9.1%) over streptokinase with subcutaneous heparin (10.1%, P =.011) and streptokinase with intravenous heparin (10.1%, P =.009). Combination therapy had an intermediate 1-year mortality (9.9%); this outcome was statistically indistinguishable from that with streptokinase ( P =.47) but was marginally different from that with accelerated TPA ( P =.05). Conclusions The 1-year results demonstrated a saving of 10 lives per 1000 patients treated with accelerated TPA versus streptokinase and subcutaneous or intravenous heparin. Combination thrombolytic therapy had an intermediate benefit but offered no advantage over accelerated TPA treatment alone.

R.J. Simes

Papers

Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion : importance of early and complete infarct artery reperfusion

Prediction of 1-Year Survival After Thrombolysis for Acute Myocardial Infarction in the Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries Trial

One-Year Results From the Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries (GUSTO-I) Trial

Selection of thrombolytic therapy for individual patients: Development of a clinical model