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European Heart Journal Advance Access originally published online on January 11, 2006
European Heart Journal 2006 27(4):419-426; doi:10.1093/eurheartj/ehi700
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© The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Forecasting mortality: dynamic assessment of risk in ST-segment elevation acute myocardial infarction

Wei-Ching Chang1, Padma Kaul1, Yuling Fu1, Cynthia M. Westerhout1, Christopher B. Granger2, Kenneth W. Mahaffey2, Lars Wallentin3, Frans Van de Werf4, Paul W. Armstrong1,* for the ASSENT-3 Investigators

1Department of Medicine, University of Alberta, 2-51 Medical Sciences Building, Edmonton, Alberta, Canada T6G 2H7
2Duke Clinical Research Institute, Durham, NC, USA
3Department of Cardiology, University Hospital of Uppsala, Uppsala, Sweden
4Center for Thrombosis and Vascular Research, Katholieke Universiteit, Leuven, Belgium

Received 25 July 2005; revised 31 October 2005; accepted 1 December 2005; online publish-ahead-of-print 11 January 2006.

* Corresponding author. Tel: +1 780 492 0951; fax: +1 780 492 9486. E-mail address: paul.armstrong{at}ualberta.ca

This paper was guest edited by Peter L. Thompson, University of Western Australia, Sir Charles Gairdner Hospital, Perth - Nedlands, Australia

Aims To demonstrate the feasibility and clinical utility of developing dynamic risk assessment models for ST-segment elevation myocardial infarction (STEMI) patients.

Methods and results In 6066 STEMI patients enrolled in the Assessment of the Safety and Efficacy of a New Thrombolytic-3 (ASSENT-3) trial with complete electrocardiographic data, we assessed the probability of 30-day mortality over the following forecasting periods beginning at day 0 (baseline), 3 h, day 2, and day 5 using multiple-logistic regression. These models were validated and simplified in independent samples of 1622 similar fibrinolytic-treated patients from the ASSENT-3 PLUS trial and in 814 STEMI patients undergoing primary percutaneous coronary intervention in the COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial. The discriminatory power of these predictive models, from baseline to day 5, was excellent (c-statistics 0.80 to 0.87); and their predictive ability was supported by strong gradients in mortality outcomes as the risk score increased. Dynamic modelling also provided information on the change in prognosis over time which may be used to advise more appropriate therapeutic decisions, e.g. the identification of high-risk patients for possible co-interventions.

Conclusion Dynamic modelling for STEMI patients enhances the risk assessment and stratification and should provide valuable ongoing guidance for their management.

Key Words: Prognosis • Dynamic modelling • Simplified risk scores • ST-segment elevation myocardial infarction


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