European Heart Journal Advance Access originally published online on April 3, 2007
European Heart Journal 2007 28(9):1079-1084; doi:10.1093/eurheartj/ehm016
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Treatment and outcomes of patients with evolving myocardial infarction: experiences from the SYNERGY trial
1 Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
2 Department of Statistics, North Carolina State University, Raleigh, NC, USA
3 Duke Clinical Research Institute, Durham, NC, USA
4 VCU Medical Center, Virginia Commonwealth University, Richmond, VA, USA
5 Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
6 Department of Emergency Medicine, Pennsylvania Hospital, Philadelphia, PA, USA
7 Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
8 Flinders Medical Centre, Bedford Park, South Australia, Australia
9 Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
10 Section of Cardiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
11 Texas Heart Institute, Houston, TX, USA
Received 3 November 2006; revised 17 January 2007; accepted 15 February 2007; online publish-ahead-of-print 3 April 2007.
* Corresponding author. Tel: +1 336 716 1740; fax: +1 336 716 5438. E-mail address: cmiller{at}wfubmc.edu
See page 1043 for the editorial comment on this article (doi:10.1093/eurheartj/ehm083)
Aims: Patients with myocardial infarction (MI) presenting immediately after symptom onset may be treated less aggressively due to their non-elevated troponin status. We compared the initial treatment and clinical outcomes of patients presenting with evolving MI (EMI) with those presenting with MI.
Methods and results: This study analysed data from the Superior Yield of the New strategy of Enoxaparin, Revascularisation, and Glycoprotein IIb/IIIa inhibitors (SYNERGY) trial, which enrolled patients meeting at least two of the following: age 
60 years, elevated cardiac biomarkers, or ST-segment changes. Patients were stratified by troponin results obtained within 12 h of presentation: EMI [initial troponin (–), second troponin (+)], MI [initial troponin (+)], and no MI at enrolment [first and second troponin (–)]. Comparisons were made using Wilcoxon rank-sum and 
2 tests. Of the 8309 patients with complete data, 5503 (66%) had MI, 1686 (20%) had EMI, and 1120 (13%) had no MI. Treatment patterns prior to enrolment were similar among EMI and MI patients [aspirin (88 vs. 86%), beta-blockers (62 vs. 61%), heparin (83 vs. 81%), and glycoprotein IIb/IIIa inhibitors (23 vs. 24%)]. Similar rates of percutaneous coronary intervention (48 vs. 50%) and coronary artery bypass grafting (21 vs. 22%) were seen after enrolment. Patients presenting with MI had a higher rate of death or recurrent MI compared with patients with EMI [16 vs. 13%, adjusted OR 1.22 (95% CI 1.04, 1.44)].
Conclusion: Initial treatment patterns were similar among patients with EMI and MI in the SYNERGY trial. Patients with EMI had lower rates of death or re-infarction at 30 days compared with patients presenting with positive troponin results.
Key Words: Evolving myocardial infarction • Troponin • Initial treatment • Outcomes
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