The prognostic value of pre-discharge exercise testing after myocardial infarction treated with either primary PCI or fibrinolysis: a DANAMI-2 sub-study.
OBJECTIVE
To evaluate the prognostic importance of pre-discharge maximal symptom-limited exercise testing (ET) following acute myocardial infarction (AMI) in the era of aggressive reperfusion.


RESULTS
In the DANAMI-2 (the second DANish trial in AMI) study, patients with ST-elevation AMI (STEMI) were randomized to primary angioplasty (PCI) or fibrinolysis. Of 1462 patients discharged alive, 1164 (79.6%) performed an ET. Primary endpoint was a composite of death and re-infarction. Patients randomized to fibrinolysis developed ST-depression to a greater extent than patients randomized to primary PCI (21.7 vs. 15.3%, P=0.007). Multivariable predictors of death and re-infarction included age, gender, diabetes, previous stroke, anterior AMI, randomization to fibrinolysis, and exercise capacity [risk ratio (RR) 0.82 (0.72-0.93); P<0.001]. ST-depression was predictive of the clinical outcome [RR 1.57 (1.00-2.48); P<0.05] in multivariable analysis, but stratified according to treatment groups there was a significant association between ST-depression and outcome in the fibrinolysis group [RR 1.95 (1.11-3.44); P<0.05], but not in the primary PCI group [RR 1.06 (0.47-2.36); P=ns]. However, the P-value for interaction was 0.15.


CONCLUSIONS
Exercise testing after contemporary reperfusion therapies for STEMI confers important prognostic information. Exercise capacity is a strong prognostic predictor of death and re-infarction irrespective of treatment strategy, whereas the prognostic significance of ST-depression seems to be strongest in the fibrinolysis-treated patients.
Valeur
Nana
N
Department of Cardiology B, The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark. nvaleur@dadlet.dk
Clemmensen
Peter
P
Saunamäki
Kari
K
Grande
Peer
P
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D005080:Exercise Test; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy; D010351:Patient Discharge; D011379:Prognosis; D012307:Risk Factors
D005343:Fibrinolytic Agents