Importance and limits of pre-hospital electrocardiogram in patients with ST elevation myocardial infarction undergoing percutaneous coronary angioplasty.

BACKGROUND: The purpose of this study is to present data on the effects of pre-hospital electrocardiogram (PH-ECG) on the outcome of ST elevation myocardial infarction (STEMI) patients treated with percutaneous coronary angioplasty (PCI) included in a registry undertaken in the Italian region of Lombardy. Pre-hospital 12-lead electrocardiogram is recommended by current guidelines in order to achieve faster times to reperfusion in patients with STEMI. METHODS: The registry includes 3901 STEMI patients who underwent primary PCI over an 18-month period. RESULTS: Mean age was 63 ± 12 years. Admission through the emergency medical system (EMS) occurred in 1603 patients (40%): they were older, more frequently had previous MI, TIMI flow = 0 at entry and were more frequently in Killip class >1 than patients who were not admitted through the EMS. Among the patients admitted through the EMS, PH-ECG was obtained in 475 patients (12%). These patients had less frequently an anterior MI, but more frequently had absence of TIMI flow at entry than patients whose ECG was not teletransmitted. Moreover, they had a significantly shorter first medical contact-to-balloon time and a trend toward a lower 30-day death rate (5.3% vs 7.9 %, p = 0.06). However, only patients in Killip class 2-3 had a significantly lower mortality when the diagnostic ECG was transmitted, whereas no difference was found in Killip class 1 or Killip class 4 patients. CONCLUSIONS: In this registry, PH-ECG significantly decreased first medical contact-to-balloon time. Attempts to achieve faster reperfusion times should be undertaken, as this may result in improved outcome, particularly in patients with mild to moderate symptoms of heart failure.

Emergency percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by out-of-hospital cardiac arrest: early and medium-term outcome.

BACKGROUND: The role of emergency reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI) resuscitated after an out-of-hospital cardiac arrest (OHCA) has not been clearly established yet. The aim of this study was to evaluate the in-hospital and postdischarge outcomes of STEMI patients surviving OHCA and undergoing emergency angioplasty (percutaneous coronary intervention [PCI]) within an established regional network. METHODS: We prospectively collected data on 2,617 consecutive patients with STEMI treated with emergency PCI in 2005; in-hospital and 6-month outcomes of 99 patients who had experienced OHCA were compared with those of 2,518 patients without OHCA. The OHCA patients also underwent a cerebral performance evaluation after 12 months. RESULTS: OHCA patients were at higher clinical risk at presentation (cardiogenic shock 26% vs 5%, P < .0001). Percutaneous coronary intervention was successful in 80% of the OHCA and 89% of the non-OHCA patients (P = NS). In-hospital mortality rates were 22% and 3%, respectively (P < .0001). Independent predictors of in-hospital mortality among OHCA patients were longer delay between the call to the emergency medical system and the start of cardiopulmonary resuscitation (odds ratio [OR] 3.5, P = .03), nonshockable initial rhythms (OR 10.5, P = .002), cardiogenic shock (OR 3.05, P = .035), and a Glasgow Coma Scale score of 3 on admission (OR 2.9, P = .032). The 6-month composite rate of death, myocardial infarction, and revascularization among OHCA patients surviving the acute phase was comparable to that of non-OHCA patients (16% vs 13.9%, P = NS), and 87% of them showed a favorable neurologic recovery after 1 year. CONCLUSIONS: Resuscitated OHCA patients undergoing emergency PCI for STEMI have worse clinical presentation and higher in-hospital mortality compared to those without OHCA. However, subsequent cardiac events are similar, and neurologic recovery is more favorable than reported in most previous series.

Galectin-3 and outcomes after anterior-wall myocardial infarction treated by primary percutaneous coronary intervention.

AIM: Galectin-3 (Gal-3), a biomarker of inflammation, tissue repair and fibrogenesis, is associated to left ventricular remodeling after ST-elevated myocardial infarction (STEMI), but its relation with long-term outcomes is unclear. METHODS: In 103 consecutive patients with a first anterior STEMI treated by primary angioplasty, we assayed Gal-3 and NT-proBNP. RESULTS: Age was 65 (56-76) years, 28% were women. During 18 ± 13 months, 20 patients (19.4%) died or were admitted for heart failure. After adjustment for age, gender, renal and ventricular function, troponin, NT-proBNP and Gal-3 independently predicted the combined end point (hazard ratio: 1.11; 95% CI: 1.05-1.17; per 1 ng/ml increase). Event-free survival was 42.3 versus 93.5% for Gal-3≥ versus <16.8 ng/ml (p < 0.001). CONCLUSION: Among anterior STEMI patients, early postangioplasty Gal-3 levels may be useful for risk stratification.

Galectin-3 predicts left ventricular remodelling after anterior-wall myocardial infarction treated by primary percutaneous coronary intervention.

OBJECTIVES: Despite modern reperfusion therapies, left ventricular remodelling (LVR) occurs frequently after an ST-elevated myocardial infarction (STEMI) and represents a strong predictor of mortality and heart failure. Galectin-3 (Gal-3), a novel biomarker involved in inflammation, tissue repair and fibrogenesis, might be a valuable predictor of LVR. METHODS: We enrolled consecutively admitted patients with a first anterior STEMI and left anterior descending artery occlusion treated by primary percutaneous coronary intervention (pPCI). Gal-3, N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiography and cardiovascular events were evaluated 48 hours after admission, at 1 and 6 months. LVR was defined as a ≥15% increase in LV end-systolic volume. RESULTS: We recruited 103 patients (28% women, aged 64.6±12 years, LV ejection fraction 47±11%). Median baseline Gal-3 and NT-proBNP levels were 13.2 ng/mL (10.8-17.1 ng/mL) and 2132 pg/mL (1019-4860 pg/mL) respectively. During 6 months of follow-up, 4 patients dropped out, 7 died and 26 (28.3%) of the 92 survivors developed LVR (LVR+). LVR+ patients had higher Gal-3 levels at baseline, 1 and 6 months than LVR- (p<0.0001). By univariable logistic regression, age, female gender, higher baseline Gal-3 and NT-proBNP, smaller LV end-diastolic volume (LVEDV) were associated to an increased risk of LVR. By multivariable analysis, only LVEDV (OR 0.96, 95% CI 0.93 to 0.99/1 mL change) and Gal-3 levels (OR 1.22, 95% CI 1.06 to 1.42/1 ng/mL change) independently predicted LVR (C-statistics 0.84, 95% CI 0.75 to 0.93). CONCLUSION: Gal-3 serum levels measured during hospitalisation could be clinically useful in predicting LVR among patients admitted with anterior STEMI treated by pPCI.

Resting echocardiographic assessment of regional wall motion, thickness and reflectivity in chronic ischemic cardiomyopathy: an alternative to the viability test?

BACKGROUND: A resting echo showing a regional end-diastolic wall thickness < or = 6 mm with a hyperechoic texture is pathognomonic of scar tissue and of non-viable myocardium. The aim of this study was to assess the prognostic value of the resting echo scar texture in patients with chronic ischemic cardiomyopathy evaluated prior to coronary artery bypass surgery. METHODS: The preoperative clinical and echocardiographic data of 70 patients with a mean ejection fraction of 29.8 +/- 4% scheduled for coronary revascularization were correlated to the cardiac events observed during a mean follow-up of 24 +/- 12 months after surgery. Akinetic segments of the left ventricular wall with a reduced diastolic thickness and increased echoreflectivity were judged scarred. RESULTS: Sixty-eight patients were discharged alive from hospital. On the basis of ROC analysis, we identified: group A (27 patients) with > 5 and group B (41 patients) with < or = 5 scarred segments. There were 10 events (3 deaths, 4 heart transplants and 3 refractory heart failures), 8 in group A (29%) and 2 in group B (5%). At multivariate analysis the only independent predictor of the clinical outcome after revascularization was whether the patient was included in group A or B (Wald 6.3, p < 0.012). One year after surgery, the ejection fraction improved only in group B patients (p < 0.03). CONCLUSIONS: The extent of scarred myocardial tissue as assessed at resting echocardiography predicted the benefit of revascularization in patients with chronic ischemic left ventricular dysfunction. This simple and straightforward echo parameter should be taken into consideration when assessing the instrumental value of more technologically demanding and costly viability testing.

[Cardiologic assessment in candidates for non-cardiac surgery]. / Valutazione cardiologica nei pazienti candidati a chirurgia non cardiaca.

Cardiovascular complications are important causes of morbidity and mortality with major non cardiac procedures. The aim of preoperative cardiac evaluation is more appropriately the initiation of a process of communication between Cardiologist, Surgeon and Anesthesiologist, with the purpose of performing an evaluation of patient's clinical risk profile and of providing the more cost-effective strategy to reduce risk of cardiac complications. There is general agreement that an accurate clinical evaluation is necessary and often sufficient for preoperative cardiac risk assessment. Several indices for prediction of cardiac complications--based on the history and physical examination of the patient--have been proposed and many of them have been validated by following studies. An effective preoperative evaluation must focus four crucial data: clinical predictors and functional capacity of the patient and, on the other side, the specific risk of the type of surgical operation and its character of election or emergency. According to the integrated valuation of these four parameters we can identify the patients who need additional noninvasive testing from those who can directly undergo noncardiac surgery. Preoperative testing should be limited to circumstances in which the results will affect patient management and outcomes. Coronary angiography and following revascularization have the same indications as if performed in the non-operative setting.

[The impact of comorbidity in the management of octogenarians with non-ST-elevation acute coronary syndrome]. / Impatto decisionale delle patologie associate nella scelta tra strategia aggressiva e conservativa nei pazienti ottuagenari con sindrome coronarica acuta senza sopraslivellamento ST.

BACKGROUND: Octogenarians are the fastest growing segment of our population and show a high prevalence of coronary disease. Despite these trends they are underrepresented in randomized controlled trials on acute coronary syndromes. Although older patients with acute coronary syndromes are at increased risk of death or reinfarction, they are less likely to be treated with an aggressive strategy. METHODS: In a retrospective analysis, we evaluated 176 consecutive octogenarians admitted to our Division of Cardiology with non-ST-elevation acute coronary syndrome, the causes of their exclusion from cardiac catheterization, and in particular the impact of associated comorbid conditions. RESULTS: Demographic characteristics, left ventricular ejection fraction and medical therapy were comparable in the groups of patients treated with a conservative or aggressive strategy. Cardiovascular risk factors and the TIMI risk score were similarly distributed between the two groups. The most important cause of exclusion from coronary angiography was the presence of comorbidity (77% of patients of this group). In order to assess the total comorbidity burden, we applied the Charlson comorbidity index to this group and found that 32% of patients excluded from aggressive strategy did not show a so severe associate disorder complexity. CONCLUSIONS: The use of a validated index to measure associated disorders is advisable in our clinical practice to properly assess illness severity, in order to not deny an interventional procedure which could improve the quality of life of the oldest patients.

[Beta-blocker therapy and risk reduction in non-cardiac surgery]. / Terapia betabloccante e riduzione del rischio nella chirurgia non cardiaca.

Cardiovascular complications are important causes of morbidity and mortality with major noncardiac procedures. Preoperative cardiac evaluation aims at assessing the patient's clinical risk profile in order to provide the more cost-effective strategy to reduce the risk of cardiac complications. Among different ways to reduce the incidence of perioperative cardiac complications, compelling evidence comes from the use of beta-blockers: in the absence of absolute contraindications, beta-blocker therapy should be administered to all patients at intermediate-high risk for coronary events who have to undergo noncardiac surgery. Even if the number of patients enrolled in these studies is relatively small, the use of beta-blockers before noncardiac surgery has been shown to be associated with a significant reduction in major cardiac events so that this therapy may reduce the need for additional noninvasive tests in some groups of patients. Coronary angiography and revascularization should have the same indications as if performed in the nonoperative setting.

[Cost reduction in the assessment of thoracic pain with the chest pain unit in first aid]. / Riduzione dei costi nella valutazione del dolore toracico con la "Chest Pain Unit" in Pronto Soccorso.

BACKGROUND: The evaluation of chest pain is a constant challenge for cardiologists, due to its clinical, organizational, economical and legal implications. The costs of the diagnostic classification of non-specific thoracic pain during ordinary, albeit short, hospitalization are here compared with a quick screening of the same symptoms in a "Chest Pain Unit", which may form an appendix of the emergency room (ER). METHODS: The study involves patients admitted to the hospital used as reference during the year 2000 and discharged with a diagnosis of thoracic pain or precordial pain, as identified by ICD-9-CM codes 786.50, 786.51, 786.52, 786.59. According to DRG 143 tariffs, the hospitalization of such a patient costs Itl 4,346,000 epsilon 2244.52). If a Chest Pain Unit should monitor the same patients in the ER for at least 12 hours, during which time the examination at admission has to followed by two ECGs, 4 seriated evaluation of cardio-specific enzymes, an echocardiogram and a stress test, the individual cost concerning payment for ER services, would be of Itl 879,000 ([symbol: see text] 453.97). Even adding Itl 508,000 ([symbol: see text] 262.36) to pay the 12-hour monitoring provided for by the short protocol, the total amount would be Itl 1,387,000 epsilon 716.33). This evaluation has also been applied to the 47,775 patients hospitalized with the same diagnosis in all Italian hospitals during the year 1999. RESULTS: Three hundred and thirty-eight patients admitted to the hospital used as reference were discharged with the above reported diagnosis. Among them 215 (64%) were hospitalized in the cardiology ward. The total cost for hospitalization for the 338 patients evaluated was Itl 1,468,948,000 epsilon 758,648.33) as compared to Itl 297,102,000 epsilon 153,440.37) that the short-term therapy would have required. Countrywide the same cost was Itl 207,543,230,000 epsilon 107,187,132.99) as compared to Itl 41,976,645,000 epsilon 21,679,127.91) for the short-term therapy, using which would have led to save Itl 166,566,585,000 epsilon 86,024,461.98). CONCLUSIONS: The suggested strategy, corroborated by many previous experiences, is an effective and efficient alternative for thoracic pain evaluation, especially in a time when economical resources are being drastically reduced, thus requiring research and application of optimized diagnostic procedures.

Outcomes and predictors of mortality among octogenarians and older with ST-segment elevation myocardial infarction treated with primary coronary angioplasty.

BACKGROUND: Elderly patients are at high risk of mortality when they present with ST-elevation myocardial infarction (STEMI). However, few data exist about prognostic factors in this sub-group when treated with primary percutaneous coronary intervention (pPCI). HYPOTHESIS: To assess outcome and predictors of mortality among patients aged >80 years treated with pPCI. METHODS: We evaluated 139 consecutive patients (age 85.1 ± 3.9 years, 43.2% males) who underwent pPCI for STEMI. RESULTS: Male patients were younger and were more likely to have a history of coronary artery disease. Overall 30-day and 1-year mortality rates were 20.9% and 28.1%, respectively. Thrombolysis in Myocardial Infarction (TIMI) flow 3 was achieved in 82% of patients. There was a pPCI success rate in male patients. At univariable analysis, older age, diabetes mellitus, Killip class >III, left ventricular ejection fraction (LVEF) <40%, no use of stent, failure of pPCI, systolic blood pressure (SBP) <100 mm Hg, and infarct-related artery (left anterior descending vs others) were associated with higher 1-year mortality. Multivariate analysis identified LVEF <40% (hazard ratio: [HR] = 3.70; 95% confidence interval [CI]: 1.30-7.87; P = 0.0001), age (1-year step, HR: 1.13; 95% CI: 1.04-1.23; P = 0.007), failure of pPCI (HR: 2.93; 95% CI: 1.44-5.98; P = 0.0001), Killip class ≥III (HR: 2.29; 95% CI: 1.03-5.4; P = 0.04) and SBP <100 mm Hg (HR: 2.64; 95% CI: 1.22-5.19; P = 0.01) to be independently associated with increased 1-year mortality. CONCLUSIONS: Our data show that elderly patients with STEMI have a high risk of mortality, which is particularly high in the first 30 days. Older age, LVEF <40% at admission, hemodynamic instability (higher Killip class or low SBP), and postinterventional TIMI flow <3 were independent predictors of mortality in our population.

Omega-6 and omega-3 polyunsaturated fatty acid levels are reduced in whole blood of Italian patients with a recent myocardial infarction: the AGE-IM study.

OBJECTIVE: The relationship between whole blood fatty acids and myocardial infarction (MI) risk has not been analyzed in detail, especially in Mediterranean countries. The AGE-IM (Acidi Grassi Essenziali e Infarto Miocardico) study was planned to examine the relationships between MI, whole blood fatty acids and the diet in an Italian cohort. METHODS: 119 Patients with a recent MI and 103 control subjects were enrolled in the study. The whole blood fatty acid composition was determined; information on anthropometrics, biochemical parameters and blood pressure values were also obtained. Diet composition was assessed using a validated food frequency questionnaire from 86 cases and 72 controls. RESULTS: Total PUFA, omega-6 and omega-3 PUFA (as percentage of whole blood fatty acids) were significantly lower in MI patients than in matched controls, whereas saturated and monounsaturated fatty acids were higher in cases. MI infarction risk significantly and steadily decreased with increasing levels of total PUFA (OR: 0.14) and of total omega-6 and omega-3 (OR: 0.15 and 0.37, respectively). No correlation was identified between dietary fats and MI risk or between whole blood fatty acid levels and dietary nutrients and fats. CONCLUSION: Percentage levels of total PUFA, total omega-3 PUFA and total omega-6 PUFA are lower in MI patients than in matched control subjects in the AGE-IM cohort. These data support a favorable association not only of whole blood percentage levels of total omega-3, but also of total omega-6, with cardiovascular risk.

Current presentation and management of 7148 patients with atrial fibrillation in cardiology and internal medicine hospital centers: the ATA AF study.

BACKGROUND: Atrial fibrillation (AF) is associated with a high risk of stroke and mortality. AIMS: To describe the difference in AF management of patients (pts) referred to Cardiology (CARD) or Internal Medicine (MED) units in Italy. METHODS AND RESULTS: From May to July 2010, 360 centers enrolled 7148 pts (54% in CARD and 46% in MED). Median age was 77 years (IQR 70-83). Hypertension was the most prevalent associated condition, followed by hypercholesterolemia (28.9%), heart failure (27.7%) and diabetes (24.3%). MED pts were older, more frequently females and more often with comorbidities than CARD pts. In the 4845 pts with nonvalvular AF, a CHADS2 score ≥ 2 was present in 53.0% of CARD vs 75.3% of MED pts (p<.0001). Oral anticoagulants (OAC) were prescribed in 64.2% of CARD vs 46.3% of MED pts (p<.0001); OAC prescription rate was 49.6% in CHADS2 0 and 56.2% in CHADS2 score ≥ 2 pts. At the adjusted analysis patients managed in MED had a significantly lower probability to be treated with OAC. Rate control strategy was pursued in 51.4% of the pts (60.5% in MED and 43.6% in CARD) while rhythm control was the choice in 39.8% of CARD vs 12.9% of MED pts (p<.0001). CONCLUSIONS: Cardiologists and internists seem to manage pts with large epidemiological differences. Both CARD and MED specialists currently fail to prescribe OAC in accordance with stroke risk. Patients managed by MED specialists have a lower probability to receive an OAC treatment, irrespective of the severity of clinical conditions.

Italian cardiological guidelines for sports eligibility in athletes with heart disease: part 1.

In Italy the existence of a law on health protection of competitive sports since 1982 has favored the creation and the revision of these cardiological guidelines (called COCIS), which have reached their fourth edition (1989-2009). The present article is the second English version, which has summarized the larger version in Italian. The experience of the experts consulted in the course of these past 20 years has facilitated the application and the compatibility of issues related to clinical cardiology to the sports medicine field. Such prolonged experience has allowed the clinical cardiologist to acquire knowledge of the applied physiology of exercise and, on the other hand, has improved the ability of sports physicians in cardiological diagnostics. All this work has produced these guidelines related to the judgment of eligibility for competitive sports in the individual clinical situations and in the different cardiovascular abnormalities and/or heart disease. Numerous arguments are debated, such as interpretation of the athlete's ECG, the utility of a preparticipation screening, arrhythmias, congenital heart disease, cardiomyopathies, arterial hypertension, ischemic heart disease and other particular issues.

Italian cardiological guidelines for sports eligibility in athletes with heart disease: part 2.

In Italy the existence of a law on health protection of competitive sports since 1982 has favored the creation and the revision of these cardiological guidelines (called COCIS), which have reached their fourth edition (1989-2009). The present article is the second English version, which has summarized the larger version in Italian. The experience of the experts consulted in the course of these past 20 years has facilitated the application and the compatibility of issues related to clinical cardiology to the sports medicine field. Such prolonged experience has allowed the clinical cardiologist to acquire knowledge of the applied physiology of exercise and, on the other hand, has improved the ability of sports physicians in cardiological diagnostics. All this work has produced these guidelines related to the judgment of eligibility for competitive sports in the individual clinical situations and in the different cardiovascular abnormalities and/or heart disease. Numerous arguments are debated, such as interpretation of the athlete's ECG, the utility of a preparticipation screening, arrhythmias, congenital heart disease, cardiomyopathies, arterial hypertension, ischemic heart disease and other particular issues.

Use of implantable cardioverter defibrillator and cardiac resynchronization therapy: an Italian survey study on 220 cardiology departments.

OBJECTIVES: To evaluate the criteria for the use of implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT) and other strategies in order to reduce the incidence of sudden death among adults at high risk and to identify the major barriers for the implementation of quality of care involving Italian cardiology departments in the context of 'Progetto Aritmie Area Scompenso Cardiaco ANMCO'. An additional aim was to evaluate how European Guidelines are applied in 'real-life' scenarios. METHODS: The clinical survey involved 220 centres. An 11-item questionnaire with prespecified multiple choice answers was used. In the specific clinical section, three clinical scenarios were described: the first concerning a patient with non-ischaemic dilated cardiomyopathy and left ventricular ejection fraction (LVEF) 35%; the second, a patient with ischaemic dilated cardiomyopathy and LVEF 30%; and the third, a patient with ischaemic dilated cardiomyopathy and LVEF between 30 and 40%. For each clinical scenario, the centres were asked to indicate whether ICD implantation should be indicated and which diagnostic tests or clinical predictors should be used to stratify the risk. RESULTS: The mean number of procedures (ICD and CRT, ICD alone, CRT alone) performed in each centre was 59 per year with a total number of 11  229 procedures per year. ICD, alone or with CRT, was the most common procedure performed with a mean number of 52 implants per centre per year. Concomitant diseases represented the most frequent (>94% of the cases) contraindication. Arrhythmic risk stratification was tested in 76.4% of the centres. Most of the centres (76.4%) stated that they routinely performed adjunctive tests, in addition to LVEF, to identify individuals at higher risk prior to ICD implantation, whereas 23.6% reported that they did not perform any risk stratification. The tools most frequently used for risk stratification (alone or in combination) were as follows: QRS duration on 12-lead ECG (71% of centres), presence of non-sustained ventricular tachycardia on 24-h recording (90%) and programmed ventricular stimulation (65%). CONCLUSION: This survey reveals a fairly good correspondence between the therapeutic choices made by the Italian centres involved in the study and the recommendations set out in the guidelines of the Italian, European and American scientific societies.

The management of acute myocardial infarction in the cardiological intensive care units in Italy: the 'BLITZ 4 Qualità' campaign for performance measurement and quality improvement.

AIM: To assess and promote compliance of Italian cardiological intensive care units (CCUs) with evidence-based guidelines for the management of acute myocardial infarction (MI). METHODS AND RESULTS: The process of diagnosis and treatment of MI was prospectively evaluated in 163 CCUs by use of 30 indicators during two enrolment phases, each followed by a feedback of both local and general performance. Overall, 5854 patients with ST-segment elevation MI (STEMI) and 5852 with non-ST-segment elevation MI (NSTEMI) were consecutively enrolled. The target for each indicator was defined as compliance with the relevant recommendations in ≥90% of suitable patients and it was met for nine (30%) and 10 (33.3%) indicators in the first and second phases, respectively. Regardless of target, a significant improvement in compliance was observed in the second phase in 10 out of 30 indicators (33.3%). Use of pre-hospital ECG, expedite delivery of reperfusion therapy, dosage of antithrombotic drugs, and non-pharmacological implementation of secondary prevention were often off target. Similar in-hospital mortality was observed in phases I and II, both in patients with STEMI (4.0 vs. 4.2%, p=0.79) and NSTEMI (1.8 vs. 2.4%, p=0.11). Overall, 30-day mortality were 5.7% for patients with STEMI and 3.4% with NSTEMI. CONCLUSIONS: Performance indicators can accurately weigh the whole process of diagnosis and treatment of patients with MI and monitor the improvements in the quality of care. In our large population of consecutive patients, satisfactory 30-day outcomes were observed despite suboptimal adherence to guidelines for some indicators of recognised prognostic relevance.

Defining high-risk patients with ST-segment elevation acute myocardial infarction undergoing primary percutaneous coronary intervention: a comparison among different scoring systems and clinical definitions.

BACKGROUND: Identification of high-risk patients with ST-segment elevation acute myocardial infarction (STEMI) is of the utmost importance for adequate patient stratification and evaluation of additive treatments. However, there is no consensus on the optimal definition of high-risk patients. METHODS: We therefore compared 5 scoring systems in the assessment of the risk of 30-day mortality in 3214 patients with STEMI treated with primary percutaneous coronary intervention (PCI). RESULTS: Clinical scores showed a large variability in risk stratifying patients. Identification of high-risk patients ranged from 15% (PAMI score ≥ 9) to 66% (McNamara definition). McNamara, Antoniucci and Brodie definitions had the best sensitivity (0.87-0.88 and 95% confidence intervals (CI) ranging from 0.82-0.93) while PAMI ≥ 9 had the best specificity (0.87 with 95% CI of 0.86-0.88), while its sensitivity was quite low (0.42). In a sample size simulation of a trial aimed at demonstrating a 33% difference in 30-day mortality between two hypothetical treatments, the number of STEMI patients needed to be screened varied from 4712 for the Brodie definition to 9038 for the PAMI ≥ 9 score. CONCLUSIONS: There is a large variability in risk stratification, sensitivity, specificity and predictive values among different scoring systems. These considerations should be taken into account when designing randomised trials.