Stress-induced cardiomyopathy and psychological wellbeing 1 year after an acute event.

Stress cardiomyopathy (SCM) typically presents similar symptoms to acute myocardial infarction (AMI). However, these symptoms differ when it comes to a transient and completely reversible myocardial dysfunction, which is frequently precipitated by acute stressful events, occurring in the absence of plaque rupture and coronary thrombosis. The purpose of this study was to investigate health-related quality of life (HRQL) and emotional burden subsequent to cardiac events in SCM patients. Thirty-seven SCM patients were compared with 37 matched AMI patients. All selected patients were assessed for HRQL and psychological distress at baseline and 1-year after the acute event. After controlling for covariates, scores on the Psychological General Well Being Index indicated that depressed mood had increased in both groups, but the increase for SCM patients was greater than for AMI patients. The AMI group displayed greater decreases than the SCM in physical quality of life and in total cardiac-related health quality of life. The percentage of patients with psychological distress increased significantly more in the SCM group than in the AMI group, and it made no difference whether the triggering event was emotional or physical. Our results suggest that, despite the more favorable medical prognosis of SCM patients, their cardiac condition being transient and resolving completely in few weeks, the psychological impact associated with their condition is more negative 1 year later than in the case of AMI patients whose medical prognosis is less favorable, and this difference is independent of type of trigger event.

Type D personality is associated with the development of stress cardiomyopathy following emotional triggers.

BACKGROUND: Stress cardiomyopathy (SCM) can be triggered by emotional events. Recently, type D personality has been established as an independent predictor of acute cardiac adverse events. PURPOSE: We sought to examine whether type D personality can be identified in SCM patients. METHODS: A case-control study with 37 SCM patients, 37 myocardial infarction (AMI) patients, who both experienced emotional triggering, and 37 SCM patients without emotional triggers was performed. The DS14 and Interview for Recent Life Events were administered. RESULTS: Twenty-eight (76 %) SCM emotional trigger patients were categorized as type D compared with 13 (43 %) SCM patients without emotional trigger and 12 (32 %) AMI patients (p < 0.001). SCM patients with emotional triggers had higher scores on the social inhibition subscale than the other patient groups. CONCLUSIONS: The present study highlights the possible link between type D, with a specific key role for social inhibition component, and increased biological reactivity to acute emotional stress.

Prognostic implication of stress echocardiography in 6214 hypertensive and 5328 normotensive patients.

Aims To compare the prognostic implication of stress echocardiography (SE) in a large cohort of hypertensive and normotensive patients with known or suspected coronary artery disease (CAD). The relative prognostic meaning of the SE result in hypertensive and normotensive patients remains to be addressed. Methods and results The study group was formed by 11 542 patients (6214 hypertensive patients; 5328 normotensive patients) who underwent exercise (n= 686), dobutamine (n= 2524), or dipyridamole (n= 8332) SE for evaluation of known (n= 4563) or suspected (n= 6979) CAD. Patients were followed up for a median of 25 months (1st quartile, 7; 3rd quartile, 57). Ischaemia on SE (new wall motion abnormality) was detected in 3209 (28%) patients. During follow-up, 1587 events (924 deaths, 663 non-fatal infarctions) occurred. Patients (n= 2764) undergoing revascularization were censored. The annual event rate was 7.0% in hypertensive and 5.7% in normotensive patients (P = 0.02) with known CAD, and 3.7% in hypertensive and 2.4% in normotensive patients (P< 0.0001) with suspected CAD. Ischaemia on stress echo, resting wall motion abnormality (RWMA), age, male sex, and diabetes mellitus were multivariable prognostic predictors in both patient groups. Analysing data according to the interaction of prognostically important echocardiographic covariates, such as ischaemia on SE and RWMA, an effective risk assessment was obtained in hypertensive as well as normotensive patients. The annual event rate was markedly higher in hypertensive than in normotensive patients with no ischaemia and no RWMA (2.5 and 1.7%, P = 0.0001). Finally, the incremental prognostic value of inducible ischaemia over clinical evaluation and resting left ventricular function was greater in hypertensive than in normotensive patients both with known and suspected CAD. Conclusion The SE result allows an effective prognostication in hypertensive and normotensive patients. However, a non-ischaemic test predicts better survival in normotensive than in hypertensive patients with no RWMA.

Information on center characteristics as costs' determinants in multicenter clinical trials: is modeling center effect worth the effort?

OBJECTIVES: Several methodological problems arise when health outcomes and resource utilization are collected at different sites. To avoid misleading conclusions in multi-center economic evaluations the center effect needs to be taken into adequate consideration. The aim of this article is to compare several models, which make use of a different amount of information about the enrolling center. METHODS: To model the association of total medical costs with the levels of two sets of covariates, one at patient and one at center level, we considered four statistical models, based on the Gamma model in the class of the Generalized Linear Models with a log link, which use different amount of information on the enrolling centers. Models were applied to Cost of Strategies after Myocardial Infarction data, an international randomized trial on costs of uncomplicated acute myocardial infarction (AMI). RESULTS: The simple center effect adjustment based on a single random effect results in a more conservative estimation of the parameters as compared with approaches which make use of deeper information on the centers characteristics. CONCLUSIONS: This study shows, with reference to a real multicenter trial, that center information cannot be neglected and should be collected and inserted in the analysis, better in combination with one or more random effect, taking into account in this way also the heterogeneity among centers because of unobserved centers characteristics.

Assessing functional mitral regurgitation with exercise echocardiography: rationale and clinical applications.

Secondary or functional mitral regurgitation (FMR) represents an increasing feature of mitral valve disease characterized by abnormal function of anatomically normal leaflets in the context of the impaired function of remodelled left ventricles. The anatomic and pathophysiological basis of FMR are briefly analyzed; in addition, the role of exercise echocardiography for the assessment of FMR is discussed in view of its relevance to clinical practice.

Direct stenting after thrombus removal before primary angioplasty in acute myocardial infarction.

OBJECTIVES: To verify whether direct stenting (DS) after thrombus removal during primary angioplasty (PPCI) in patients with ST-elevation acute myocardial infarction (STEMI) can improve myocardial reperfusion and prevent distal embolization compared to conventional stent implantation. BACKGROUND: Both mechanical removal and DS reduce thrombus dislodgment and improve microcirculatory reperfusion during PPCI. However, the additional effect of DS after thrombus removal has not been definitely assessed. METHODS: The DEAR-MI study included 148 consecutive STEMI patients who were randomly assigned to undergo or not thrombus aspiration before PPCI. For the purpose of the present study, we interrogated the DEAR-MI data bank to compare the occurrence of complete (>70%) ST-segment resolution (STR), myocardial blush grade (MBG)-3, no-reflow, and angiographic embolization in patients treated and untreated with DS. RESULTS: Clinical and angiographic characteristics were similar in the two groups. Comparing DS and no-DS groups, complete STR was found in 67% versus 51% (P = 0.08), MBG-3 in 86% versus 49% (P < 0.001), no-reflow in 1% versus 14% (P < 0.01), angiographic embolization in 3% versus 19% (P < 0.01), TIMI flow-3 in 89% versus 70% (P < 0.01), and the corrected TIMI frame count was 16.2 versus 18.8 (P < 0.05). Among patients undergoing thrombus aspiration, the odds ratio of DS for MBG-3 and distal embolization was 4 (95% CI 1-16.6) and 0.10 (95% CI 0.01-0.93), respectively. At multivariable analysis, thrombus aspiration (P < 0.001) and DS (P < 0.05) independently predicted MBG-3, while thrombus aspiration was the only independent predictor of DS. CONCLUSIONS: DS during PPCI reduces distal embolization and improves myocardial reperfusion. This effect is significantly more relevant after thrombus aspiration.

Comparison of the prognostic value of the stress-recovery index versus standard electrocardiographic criteria in patients with a negative exercise electrocardiogram.

To verify whether the stress recovery index (SRI) improves risk stratification in patients with a negative exercise electrocardiogram (ECG) using standard criteria, the SRI was derived in 708 consecutive patients with a negative exercise ECG. All-cause mortality and the combination of death or nonfatal myocardial infarction were target end points. The individual effect of clinical and exercise testing data on outcome was evaluated using Cox regression analysis with separate models for each group of variables. Model validation was performed using bootstrap adjusted by degree of optimism in estimates. Survival analysis was performed using a product-limit Kaplan-Meier method. During a 37-month follow-up, 22 deaths and 40 nonfatal acute coronary syndromes occurred. After adjusting for confounding variables, age (hazard ratio 1.62, 95% confidence interval [CI] 1.14 to 2.31 for interquartile difference), hypertension (hazard ratio 1.74, 95% CI 1.04 to 2.89), and SRI (hazard ratio 0.75, 95% CI 0.65 to 0.86 for interquartile difference) were predictive of death or nonfatal myocardial infarction. Moreover, SRI increased the prognostic power of the model on top of clinical and exercise testing variables and provided significant discrimination of survival. In conclusion, the SRI may help refine the prognostic stratification of patients with a negative exercise test result using standard electrocardiographic criteria.

Prognostic implications of dipyridamole or dobutamine stress echocardiography for evaluation of patients > or =65 years of age with known or suspected coronary heart disease.

This study investigated the value of pharmacologic stress echocardiography for risk stratification of patients > or =65 years of age. The study cohort consisted of 2,160 patients > or =65 years of age (1,257 men, mean +/- SD 71 +/- 5 years of age) undergoing dipyridamole (n = 1,521) or dobutamine (n = 639) stress echocardiography for evaluation of known (n = 913) or suspected (n = 1,247) coronary artery disease. Of 2,160 patients, 753 (35%) had a normal test result, whereas 772 (36%) showed a myocardial ischemic pattern and 635 (29%) a scar pattern. During a median follow-up of 26 months, 241 deaths and 87 nonfatal myocardial infarctions occurred. Patients (n = 568) undergoing revascularization were censored. Of 16 analyzed variables, age (hazard ratio [HR] 1.07 per unit increment), wall motion score index at rest (HR 2.63 per unit increment), ischemia at stress echocardiography (HR 1.81), and diabetes (HR 1.57) were multivariable predictors of death, whereas age (HR 1.06 per unit increment), ischemia at stress echocardiography (HR 2.60), wall motion score index at rest (HR 1.98 per unit increment), scar pattern (HR 1.99), and diabetes (HR 1.48) were multivariable predictors of death or myocardial infarction. Using an interactive stepwise procedure, stress echocardiography showed incremental prognostic value over clinical and echocardiographic data at rest, which decreased with increasing age. In addition, the annual hard event rate associated with a normal test result progressively increased with age. In conclusion, pharmacologic stress echocardiography provides useful prognostic information in patients > or =65 years of age. However, its prognostic value decreases with increasing age.

Comparison of prognostic value of pharmacologic stress echocardiography in chest pain patients with versus without diabetes mellitus and positive exercise electrocardiography.

The aim of this study was to compare the prognostic value of pharmacologic stress echocardiography in diabetic and nondiabetic patients with chest pain and intermediate- to high-threshold positive exercise electrocardiographic results. A total of 935 patients with chest pain (131 diabetic patients) with ST-segment depression > or =1 mm on exercise electrocardiography at > or =75-W workload underwent dipyridamole (n = 786) or dobutamine (n = 149) stress echocardiography and were followed up for the occurence of hard (death and infarction) and major events (death, infarction, and late revascularization). During a median follow-up of 26 months, 158 events (51 deaths, 28 myocardial infarctions, and 79 late revascularizations) occurred: 34 in diabetic and 124 in nondiabetic patients (26% vs 15%, p = 0.003). Independent predictors of hard events were age, diabetes, and ischemia at stress echocardiography. Five-year hard event rates were 24% in patients with and 4% in those without ischemia (p <0.0001). Independent predictors of major events were age, diabetes, hypercholesterolemia, smoking habit, antianginal therapy at the time of testing, and ischemia at stress echocardiography. Five-year major event rates were 46% in patients with and 7% in those without ischemia (p <0.0001). Stress echocardiography results yielded effective prognostic information in diabetic and nondiabetic patients. However, the latter had worse outcomes in both the presence and absence of ischemia. Nevertheless, a nonischemic test result predicted an uneventful 6-month period and 2% major event rate at 1-year follow-up in both populations. In conclusion, stress echocardiography was effective in risk stratifying diabetic and nondiabetic patients with intermediate- to high-threshold ischemic exercise electrocardiographic results. However, major event rates associated with a nonischemic test result were similar in diabetic and nondiabetic patients during the first year of follow-up and markedly increased in the former thereafter.

Dobutamine stress echocardiography and the effect of revascularization on outcome in diabetic and non-diabetic patients with chronic ischaemic left ventricular dysfunction.

AIM: To evaluate the interaction between prognostic effect of revascularization and viability in diabetic and non-diabetic patients with ischaemic left ventricular dysfunction. METHODS: 612 patients with angiographically proven coronary artery disease and left ventricular ejection fraction <35% underwent dobutamine stress echocardiography to assess viability (peak-rest wall motion score index >0.4). 262 patients (75 diabetics, 187 non-diabetics) underwent revascularization and 350 (88 diabetics, 262 non-diabetics) were on medical therapy. RESULTS: During follow-up 215 patients died. Independent predictors of mortality in revascularized patients were resting left ventricular ejection fraction (HR=0.93, 95% CI 0.89-0.97, p<0.0001), Delta WMSI>40 (HR=0.44, 95% CI 0.23-0.85, p=0.01), and age (HR=1.03, 95% CI 1.00-1.06, p=0.04). In medically treated patients, independent predictors of mortality were diabetes mellitus (HR=1.64, 95% CI 1.13-2.38, p=0.009), number of diseased vessels (HR=1.27, 95% CI 1.03-1.56, p=0.02), and age (HR=1.02, 95% CI 1.00-1.04, p=0.03). In revascularized patients, 4-year mortality was 15% in those with viability and 26% in those without viability (p=0.04), there was no difference between diabetics and non-diabetics (24% vs 22%; p=0.24). CONCLUSIONS: Viability at dobutamine stress echocardiography independently predicts improved outcome following revascularization in non-diabetics as well as diabetic patients with ischaemic left ventricular dysfunction.

Ultrasound imaging versus morphopathology in cardiovascular diseases: the heart failure.

This review article summarizes the results of histopathological studies to assess heart failure in humans. Different histopathological features underlying the clinical manifestations of heart failure are reviewed. In addition, the present role of echocardiographic techniques in assessing the failing heart is briefly summarized.

Combined assessment of left ventricular perfusion and function by gated single-photon emission computed tomography for the risk stratification of high-risk hypertensive patients.

OBJECTIVE: This study was aimed at verifying whether combined information on left ventricular perfusion and function by electrocardiogram-gated single-photon emission computed tomography (SPECT) retains its known prognostic value in patients with systemic hypertension. METHODS: A total of 415 hypertensive patients underwent rest and stress (exercise in 278 and dipyridamole in 137) gated 99mTc-sestamibi SPECT and prospective follow-up for the composite endpoint of death and acute coronary syndrome. Patients undergoing revascularization were censored. The individual effect of clinical and stress imaging data on outcome was evaluated by Cox regression analysis. Model validation was performed using bootstrap methods adjusted by the degree of optimism in estimates. Survival analysis was performed using the product-limit Kaplan-Meier method. RESULTS: During a median follow-up of 24 months, 12 cardiac deaths and 32 acute coronary syndromes occurred. After adjusting for the most significant covariates, age [hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.02-2.57], diabetes (HR 7.51, 95% CI 1.61-35.2), summed stress score (HR 2.06, 95% CI 1.07-4), and peak end-systolic volume (HR 3.62, 95% CI 1.35-9.69) were multivariable predictors of outcome. The normal perfusion pattern was associated with a low event rate independently of peak end-systolic volume. Conversely, in the case of moderate to severe perfusion abnormalities, a peak end-systolic volume greater than 74 ml was able to identify an increased risk of adverse outcome. Moreover, peak end-systolic volume was significantly higher among patients who died of a cardiac cause compared with those with different outcomes. CONCLUSION: A combined assessment of left ventricular perfusion and function by gated SPECT significantly improves risk stratification in hypertensive patients.

Prognostic value of combined exercise and recovery electrocardiographic analysis.

BACKGROUND: Heart rate-adjusted ST-segment depression (ST/HR) analysis improves the diagnostic accuracy of exercise testing, but its prognostic value has not been evaluated in unselected populations. We prospectively used comparative exercise-recovery ST/HR analysis to predict outcome in a consecutive cohort of outpatients referred for exercise testing. METHODS: The stress-recovery index, defined as the difference between ST/HR areas during exercise and recovery,was derived in 1163 patients (median age, 60 years; interquartile range, 54-65 years). All-cause mortality and the combination of death or nonfatal myocardial infarction were target end points. The individual effect of clinical and exercise-testing data on outcome was evaluated by Cox regression analysis using separate models for each group of variables. Model validation was performed using bootstrap methods adjusted by the degree of optimism in estimates. Survival analysis was performed with the product-limit Kaplan-Meier method. RESULTS: During a 33-month follow-up, 48 deaths and 72 nonfatal myocardial infarctions occurred. After adjusting for confounding variables, hypertension (hazard ratio, 1.80; 95% confidence interval, 1.26-2.59), ST/HR index (hazard ratio, 1.32; 95% confidence interval, 1.04-1.66; for interquartile difference), and stress-recovery index (hazard ratio, 0.75; 95% confidence interval, 0.65-0.86; for interquartile difference) were predictive of death or nonfatal myocardial infarction, whereas hypertension (hazard ratio, 3.67; 95% confidence interval, 2.00-6.73) and stress-recovery index (hazard ratio, 0.55; 95% confidence interval, 0.48-0.63; for interquartile difference) were predictive of all-cause mortality. In addition, stress-recovery index increased the prognostic power of the model on top of clinical and exercise-testing variables and provided significant discrimination for survival. CONCLUSION: Combined evaluation of ST/HR analysis during exercise and recovery improves the prognostic capacity of standard exercise electrocardiography.

[Exercise electrocardiography for diagnostic and prognostic assessment of coronary disease. Recent advances]. / Recenti acquisizioni sull'analisi dei risultati dell'elettrocardiogramma da sforzo per la diagnosi e la prognosi della cardiopatia ischemica.

This article focuses on recent advances on exercise electrocardiography (ECG) for the diagnostic and prognostic assessment of coronary artery disease. In particular, the pathophysiological background of comparative heart rate-adjusted ST-segment analysis during exercise and recovery phase is discussed. In addition, the results of recent studies dealing with the application of this ECG analysis modality to different clinical settings are presented.

Prognostic value of pharmacological stress echocardiography is affected by concomitant antiischemic therapy at the time of testing.

BACKGROUND: The aim of this study was to determine whether antianginal medications affect the prognostic value of pharmacological stress echocardiography. METHODS AND RESULTS: From the EPIC-EDIC Data Bank, 7333 patients (5452 men; age; 59+/-10 years) underwent pharmacological stress echocardiography with either high-dose dipyridamole (0.84 mg/kg over 10 minutes; n=4984) or high-dose dobutamine (up to 40 microg x kg(-1) x min(-1); n=2349) (DET) for diagnostic purposes. At the time of testing, 1791 patients were on antiischemic therapy (nitrates and/or calcium antagonists and/or beta-blockers). Patients were followed up for a mean of 2.6 years (range, 1 to 206 months). DET was positive for myocardial ischemia in 2854 patients (39%) and negative in 4479 (61%). Total mortality was 336 (4.5%). Death was attributed to cardiac causes in 161 patients (2.1%). Survival was highest in patients with negative DET off therapy and lowest in patients with positive DET studied on therapy (95% versus 81%; P=0.0000). Survival was comparable in patients with a negative test on therapy and in patients with a positive test off therapy (88% versus 84%, P=NS). CONCLUSIONS: Ongoing antiischemic therapy at the time of testing heavily modulates the prognostic value of pharmacological stress echo. In the presence of concomitant antiischemic therapy, a positive test is more prognostically malignant, and a negative test less prognostically benign.

Simultaneous echocardiography and myocardial perfusion single photon emission computed tomography associated with dobutamine stress to predict long-term cardiac mortality in normotensive and hypertensive patients.

BACKGROUND: Echocardiography and myocardial scintigraphy associated with dobutamine stress are used for assessing risk in coronary artery disease. We compared the accuracy of the two modalities applied simultaneously for predicting long-term cardiac mortality in normotensive and hypertensive patients. METHODS: Three hundred and fifty-one consecutive patients underwent dobutamine stress with simultaneous echocardiography and Tc-sestamibi single photon emission computed tomography (SPECT). Fifty patients underwent early (<60 days) revascularization and were excluded; the analysis is based on 301 patients (131 hypertensives and 170 normotensives). RESULTS: The prevalence of additional risk factors, heart failure, prior myocardial infarction and prior revascularization was similar in the two groups of patients. An abnormal stress echocardiogram was detected in 101 (59%) normotensives and 80 (61%) hypertensives (NS), while 113 (66%) normotensives and 83 (63%) hypertensives (NS) showed abnormal myocardial perfusion. The agreement was 81% (kappa = 0.59) in hypertensives and 82% (kappa = 0.62) in normotensives. During 7.3 +/- 2.8 years of follow-up, 17 (13%) hypertensives and 26 (15%) normotensives died from cardiac causes (P = 0.62). In normotensives, the annual mortality rate was 0.8 for normal echo and 1.3 for normal scan, 2.8 for abnormal echo and 2.6 for abnormal scan. In hypertensives, it was 0.5 for normal echo, 0% for normal scan, 2.6 for abnormal echo and 2.8 for abnormal scan. Each test was associated with higher survival in the case of negative compared to positive results in both normotensive and hypertensive patients (log-rank chi-square 16.4, P < 0.001). CONCLUSIONS: Dobutamine stress echocardiography and SPECT are equally effective in predicting long-term cardiac death in both normotensive and hypertensive patients.

Prognostic value of a multiparametric risk score in patients undergoing dipyridamole stress echocardiography.

To set up a prognostic score including clinical data and stress echocardiographic findings, the data of 3,969 patients who underwent dipyridamole stress were analyzed. Age (hazard ratio [HR] 3.21), peak wall motion score index (HR 2.62), diabetes mellitus (HR 2.36), and male gender (HR 1.69) were independent predictors of mortality and were incorporated into a prognostic score allowing us to estimate 1-, 3-, and 5-year survival in the patient cohort. The multiparametric risk score, immediately available at the bedside, can be used to predict the survival of patients undergoing dipyridamole stress echocardiography.

Relation of terminal QRS distortion to left ventricular functional recovery and remodeling in acute myocardial infarction treated with primary angioplasty.

The association between admission electrocardiogram and 6-month change in left ventricular function and volume was assessed in 200 patients who had acute myocardial infarction that was treated with primary percutaneous coronary intervention. Logistic regression analysis indicated peak creatine phosphokinase-MB, number of Q-wave leads, QRS interval distortion, wall motion score index, and angiographic Thrombolysis In Myocardial Infarction flow grade as predictors of no functional recovery and QRS interval distortion and Thrombolysis In Myocardial Infarction flow grade as predictors of left ventricular remodeling.

Stress recovery index for risk stratification of asymptomatic patients following coronary bypass surgery.

OBJECTIVE: To prospectively assess the prognostic value of the stress recovery index (SRI) following coronary bypass surgery. DESIGN AND PATIENTS: Two hundred seventy-eight patients who had undergone coronary bypass surgery and participated in a secondary prevention program were exercise tested and prospectively followed up for a median of 36 months. Cardiac death, nonfatal infarction, and need for further revascularization were target end points. SRI, defined as the difference in absolute values between the area of heart rate-adjusted ST-segment depression during exercise and recovery, was derived in all. Clinical data, resting ejection fraction, and exercise testing data of patients were entered into a sequential Cox model; SRI was entered last. Model validation was performed by bootstrap adjusted by the degree of optimism in estimates. Survival curves were set up using Kaplan-Meier method and compared by the log-rank test. RESULTS: SRI was the only significant and independent prognostic indicator (hazard ratio, 0.68; 95% confidence interval, 0.53 to 0.89) and increased the prognostic power of the model on top of clinical and exercise testing variables, as demonstrated by the significant (p = 0.01) increase of the area under the receiver operating characteristic curve of the risk function. Survival analysis showed ascending SRI quartiles to identify a significant (p = 0.001) increase in event-free survival. CONCLUSIONS: SRI is of value in predicting outcome after coronary bypass surgery and provides additional prognostic information over clinical and exercise testing data.

Artificial neural networks and robust Bayesian classifiers for risk stratification following uncomplicated myocardial infarction.

OBJECTIVE: To compare artificial neural networks (ANN) and robust Bayesian classifiers (RBC) in predicting outcome following acute myocardial infarction (AMI). METHODS: Clinical, exercise ECG and stress echo variables by 496 patients with AMI were used to predict the cumulative end-point of cardiac death, nonfatal reinfarction and unstable angina. Revascularized patients were censored. Short (200 days)-, medium (400 days)- and long (1000 days)-term observation intervals, including 50%, 75% and 90% of the events, respectively, were considered. At each interval, any patient was binary assigned to the "event" or "no event" class. A multilayer feedforward ANN, trained by a back propagation algorithm, was used. RBC, using the leave-one-out technique, were derived. The accuracy of both techniques was compared to the default accuracy (DA) obtained by assigning all subjects to the largest class. RESULTS: 14 death, 27 reinfarction and 29 unstable angina were observed during a mean follow-up of 24 [95% confidence interval (CI) 19 to 22] months. The accuracy of ANN and RBC and DA were 70%, 81% and 74% at short, 67%, 73% and 56% at medium and 64%, 68% and 62% at long-term follow-up. CONCLUSIONS: (1) ANN do not improve the prognostic classification of patients with uncomplicated AMI as compared to RBC. (2) In particular, short-term prognostic accuracy seems insufficient.