Time-dependent predictors of primary cardiac arrest in patients with acute myocardial infarction.
To understand predictors of cardiac arrest early in acute myocardial infarction (AMI), for the Thrombolytic Predictive Instrument, we developed a multivariable regression model predicting primary cardiac arrest using time-dependent variables based on a case-control study of emergency department (ED) patients with AMI: 65 cases with sudden cardiac arrest and 258 without cardiac arrest. Within the first hour of AMI symptom onset, adjusting for age, systolic blood pressure, serum potassium, and infarct size, increased risk of cardiac arrest was associated with electrocardiographic prolonged QTc interval and a greater sum of ST-segment elevation. After 1 hour, the effect of ST-segment elevation was much reduced and the effect of the QTc interval was reversed, so prolonged QTc appeared protective. Accordingly, for patients presenting 30 minutes after chest pain onset, compared with a QTc of 0.44, the risk for cardiac arrest for patients with QTc of 0.50 was more than doubled (odds ratio [OR] 2.20, 95% confidence intervals [CI] 1.17 to 4.13), whereas for those presenting after an hour, it was much lower (e.g., at 1.5 hours, OR 0.21, 95% CI 0.06 to 0.73). Patients presenting 30 minutes after chest pain onset with a sum of ST elevation of 20 mm had a threefold higher risk than patients with a sum of ST elevation of 5 mm (OR 3.37, 95% CI 1.83 to 6.20). However, if presenting 1.5 hours after chest pain onset, the risk was barely elevated (OR 1.18; 95% CI 1.09 to 1.29). Thrombolytic therapy was protective, halving the odds of cardiac arrest (OR 0.51, 95% CI 0.27 to 0.93). Thus, the relation of prolonged QTc interval and substantial ST segment elevation to cardiac arrest in AMI may be obscured because patients with these risks are more likely to die soon after AMI onset, before ED presentation, and are thereby unavailable for study. Those with prolonged QTc or substantial ST elevation who survive the initial 1.5-hour period are those less susceptible to these risks.
Selker
Harry P
HP
Center for Cardiovascular Health Services Research, Division of Clinical Care Research, Department of Medicine, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts 02111, USA. hselker@lifespan.org
Raitt
Merritt H
MH
Schmid
Christopher H
CH
Laks
Michael M
MM
Beshansky
Joni R
JR
Griffith
John L
JL
Califf
Robert M
RM
Selvester
Ronald H
RH
Maynard
Charles
C
D'Agostino
Ralph B
RB
Weaver
W Douglas
WD
D000368:Aged; D016022:Case-Control Studies; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006323:Heart Arrest / Q000209:etiology*; D006801:Humans; D008297:Male; D008955:Models, Cardiovascular; D009203:Myocardial Infarction / Q000150:complications / Q000503:physiopathology*; D011237:Predictive Value of Tests; D013997:Time Factors