title: Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators.
abstract: BACKGROUND
  Recurrent ischemia after an acute coronary syndrome portends an unfavorable outcome and has major resource-use implications. This issue has not been studied systematically among the spectrum of patients with acute coronary presentations, encompassing those with and without ST-segment elevation.
  
  
  RESULTS
  We assessed the 1-year prognosis of the 12 142 patients enrolled in the GUSTO-IIb trial by the presence (n=4125) or absence (n=8001) of ST-segment elevation. This latter group was further categorized into those with baseline myocardial infarction (n=3513) or unstable angina (n=4488). We also assessed the incidence of recurrent ischemia and its impact on outcomes. Recurrent ischemia was significantly rarer in those with ST-segment elevation (23%) than in those without (35%; P<0.001). Mortality at 30 days was greater among patients with ST-segment elevation (6.1% versus 3.8%; P<0.001) but less so at 6 months; by 1 year, mortality did not differ significantly (9.6% versus 8.8%). Patients with non-ST-segment-elevation infarction had higher rates of reinfarction at 6 months (9.8% versus 6.2%) and higher 6-month (8.8% versus 5.0%) and 1-year mortality rates (11.1% versus 7.0%) than such patients who had unstable angina.
  
  
  CONCLUSIONS
  Refractory ischemia was associated with an approximate doubling of mortality among patients with ST-segment elevation and a near tripling of risk among those without ST elevation. This study highlights not only the substantial increase in late mortality and reinfarction with non-ST-segment-elevation infarction but also the opportunities for better triage and application of therapeutic strategies for patients with recurrent ischemia.
authors.affiliation: University of Alberta, Edmonton, Alberta, Canada. paul.armstrong@ualberta.ca
authors.forename: P W
authors.initials: PW
authors.lastname: Armstrong
authors.forename: Y
authors.initials: Y
authors.lastname: Fu
authors.forename: W C
authors.initials: WC
authors.lastname: Chang
authors.forename: E J
authors.initials: EJ
authors.lastname: Topol
authors.forename: C B
authors.initials: CB
authors.lastname: Granger
authors.forename: A
authors.initials: A
authors.lastname: Betriu
authors.forename: F
authors.initials: F
authors.lastname: Van de Werf
authors.forename: K L
authors.initials: KL
authors.lastname: Lee
authors.forename: R M
authors.initials: RM
authors.lastname: Califf
mesh_terms: D000208:Acute Disease; D000368:Aged; D000789:Angina, Unstable / Q000175:diagnosis / Q000401:mortality; D003327:Coronary Disease / Q000175:diagnosis / Q000401:mortality*; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008955:Models, Cardiovascular; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality; D011237:Predictive Value of Tests; D011379:Prognosis; D012008:Recurrence; D012307:Risk Factors