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European Heart Journal 2001 22(21):1997-2006; doi:10.1053/euhj.2001.2750
Copyright © 2001 by the European Society of Cardiology.
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Recurrent ischaemia during continuous multilead ST-segment monitoring identifies patients with acute coronary syndromes at high risk of adverse cardiac events; meta-analysis of three studies involving 995 patients

K.M. Akkerhuisa,f1, P.A.J. Klootwijka, W. Lindeboomb, V.A.W.M. Umansc, S. Meija, P.-P. Kintb and M.L. Simoonsa

a The Thoraxcenter, University Hospital Rotterdam, The Netherlands
b Cardialysis, Clinical Research Management and Core Laboratories, Rotterdam, The Netherlands
c Division of Cardiology, Medical Center Alkmaar, The Netherlands

revised March 27, 2001; accepted April 21, 2001

Abstract

Aims Recurrent ischaemia, detected by continuous ECG monitoring, in patients with unstable angina increases the risk of unfavourable outcome. Studies that evaluated this relationship have been limited by the small series of patients. By combining data from three studies, the present analysis aims to provide an accurate assessment of the impact of recurrent ischaemia detected by multilead ECG-ischaemia monitoring on the occurrence of death and myocardial infarction in patients with acute coronary syndromes.

Methods and Results Data were obtained from CAPTURE, PURSUIT and FROST, three trials evaluating glycoprotein IIb/IIIa blockers in patients with non-ST-elevation acute coronary syndromes. Patients were monitored for 24h after enrolment with a computer-assisted 12-lead or a vectorcardiographic ECG–ischaemia monitoring device. In a retrospective blinded analysis, recurrent ischaemic episodes were identified by a computer algorithm. The number of ischaemic episodes was normalized to 24h. Ischaemic episodes were detected in 271 (27%) of 995 patients. There was a direct proportional relationship between the number of ischaemic episodes per 24h and the probability of cardiac events at 5 and 30 days. The 30-day composite of death and myocardial infarction occurred in 5·7% of patients without episodes and increased to 19·7% in patients with ≥5 episodes. After adjustment for baseline predictors of adverse outcome, the relative risk of death or myocardial infarction at 5 and 30 days increased by 25% for each additional ischaemic episode per 24h.

Conclusions This analysis emphasizes the need for integration of multilead ECG–ischaemia monitoring systems in coronary care units and emergency wards to improve early risk stratification in patients with acute coronary syndromes.

Key Words: Electrocardiography, ischaemia, acute coronary syndromes, unstable angina, ECG monitoring, prognosis

f1 Correspondence: K. Martijn Akkerhuis, MD, PhD, University Hospital Rotterdam, Room H 543, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.

References

  1. Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med. 1986;314:1214–1219[Abstract]
  2. Nademanee K, Intarachot V, Josephson MA. Prognostic significance of silent myocardial ischemia in patients with unstable angina. J Am Coll Cardiol. 1987;10:1–9[Abstract]
  3. Arnim TV, Krawietz GW, Hofling B. Prognostic implications of transient-predominantly silent-ischemia in patients with unstable angina pectoris. Eur Heart J. 1988;8:435–440
  4. Patel DJ, Knight CJ, Holdright DR. Long-term prognosis in unstable angina. The importance of early risk stratification using continuous ST segment monitoring. Eur Heart J. 1998;19:240–249[Abstract/Free Full Text]
  5. Klootwijk P, Meij S, Melkert R, Lenderink T, Simoons ML. Reduction of recurrent ischemia with abciximab during continuous ECG-ischemia monitoring in patients with unstable angina refractory to standard treatment (CAPTURE). Circulation. 1998;98:1358–1364[Abstract/Free Full Text]
  6. Holmvang L, Andersen K, Dellborg M. Relative contributions of a single-admission 12-lead electrocardiogram and early 24-hour continuous electrocardiographic monitoring for early risk stratification in patients with unstable coronary artery disease. Am J Cardiol. 1999;83:667–674[CrossRef][ISI][Medline]
  7. Norgaard BL, Andersen K, Dellborg M, Abrahamsson P, Ravkilde J, Thygesen K. Admission risk assessment by cardiac troponin-T in unstable coronary artery disease: additional prognostic information from continuous ST-segment monitoring. J Am Coll Cardiol. 1999;33:1519–1527[Abstract/Free Full Text]
  8. Jernberg T, Lindahl B, Wallentin L. ST-segment monitoring with continuous 12-lead ECG improves early risk stratification in patients with chest pain and ECG nondiagnostic of acute myocardial infarction. J Am Coll Cardiol. 1999;34:1413–1419[Abstract/Free Full Text]
  9. Akkerhuis KM, Maas ACP, Klootwijk PAJ. Recurrent ischemia during continuous 12-lead ECG-ischemia monitoring in patients with acute coronary syndromes treated with eptifibatide: relation with death and myocardial infarction. J Electrocardiol. 2000;33:127–136[CrossRef][ISI][Medline]
  10. Klootwijk P, Meij S, van Es GA. Comparison of usefulness of computer-assisted continuous 48-h 3-lead with 12-lead ECG-ischaemia monitoring for detection and quantitation of ischaemia in patients with unstable angina. Eur Heart J. 1997;18:931–940[Abstract/Free Full Text]
  11. Dellborg M, Malmberg K, Rydén L, Svensson A, Swedberg K. Dynamic on-line vectorcardiography improves and simplifies in-hospital ischemia monitoring of patients with unstable angina. J Am Coll Cardiol. 1995;26:1501–1507[Abstract]
  12. Akkerhuis KM, Neuhaus KL, Wilcox RG. Safety and preliminary efficacy of one-month glycoprotein IIb/IIIa inhibition with lefradafiban in patients with acute coronary syndromes without persistent ST-elevation. Eur Heart J. 2000;21:2042–2055[Abstract/Free Full Text]
  13. Lancet. 1997;349:1429–1435[CrossRef][ISI][Medline]
  14. N Engl J Med. 1998;339:436–443[Abstract/Free Full Text]
  15. Frank E. Accurate, clinically practical system for spatial vectorcardiography. Circulation. 1956;13:737–744[ISI][Medline]
  16. Dower GE, Machado HB, Osborne JA. On deriving the electrocardiogram from vectorcardiographic leads. Clin Cardiol. 1980;3:87–95[Medline]
  17. Boersma E, Pieper KS, Steyerberg EW. Predictors of outcome in patients with acute coronary syndromes without persistent ST-elevation: results from an international trial of 9,461 patients. Circulation. 2000;101:2557–2567[Abstract/Free Full Text]
  18. Roe MT, Harrington RA, Prosper DM. Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease. Circulation. 2000;102:1101–1106[Abstract/Free Full Text]
  19. Savonitto S, Ardissino D, Granger CB. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA. 1999;281:707–713[Abstract/Free Full Text]
  20. Ravkilde J, Nissen H, Horder M, Thygesen K. Independent prognostic value of serum creatine kinase isoenzyme-MB mass, cardiac troponin-T and myosin light-chain levels in suspected acute myocardial infarction. J Am Coll Cardiol. 1995;25:574–581[Abstract]
  21. Lindahl B, Venge P, Wallentin L. Relation between troponin-T and the risk of subsequent cardiac events in unstable coronary artery disease. The FRISC study group. Circulation. 1996;93:1651–1657[Abstract/Free Full Text]
  22. Klootwijk P, Hamm CW. Acute coronary syndromes: diagnosis. Lancet. 1999;353:10–15[CrossRef]
  23. Hamm CW, Heeschen C, Goldmann B. Benefit of abciximab in patients with refractory unstable angina in relation to serum troponin-T levels. N Engl J Med. 1999;340:1623–1629[Abstract/Free Full Text]
  24. Heeschen C, Hamm CW, Goldmann B, Deu A, Langenbrink L, White HD. Troponin concentrations for stratification of patients with acute coronary syndromes in relation to therapeutic efficacy of tirofiban. Lancet. 1999;354:1757–1762[CrossRef][ISI][Medline]
  25. Boersma E, Akkerhuis KM, Theroux P, Califf RM, Topol EJ, Simoons ML. Platelet glycoprotein IIb/IIIa receptor inhibition in non-ST-elevation acute coronary syndromes: Early benefit during medical treatment only, with additional protection during percutaneous coronary intervention. Circulation. 1999;100:2045–2048[Abstract/Free Full Text]
  26. Ronner E, Boersma E, Harrington RA, Lincoff AM, Deckers JW, Simoons ML. Optimal timing of percutaneous intervention (PCI) in unstable angina. Circulation. 1999;100:I-455
  27. Lancet. 1999;354:708–715[CrossRef][ISI][Medline]
  28. Pitt B. Risk stratification in patients with unstable angina. 'Deja vue all over again?'. Circulation. 1996;93:1618–1620[Free Full Text]
  29. Jernberg T, Abrahamsson P, Lindahl B. Continuous multi-lead ST-monitoring identifies patients with unstable coronary artery disease who benefit from long-term antithrombotic treatment. FRISC-II substudy. Eur Heart J. 2000;21:P-2819
  30. Jernberg T, Abrahamsson P, Lindahl B. Does continuous vectorcardiography and continuous 12-lead ECG in patients identify the same patients in unstable coronary artery disease. Eur Heart J. 2000;21:P-2820

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