ST-segment deviation on the admission electrocardiogram, treatment strategy, and outcome in non-ST-elevation acute coronary syndromes A substudy of the Invasive versus Conservative Treatment in Unstable coronary Syndromes (ICTUS) Trial.
BACKGROUND
We assessed the prognostic significance of the presence of cumulative (Sigma) ST-segment deviation on the admission electrocardiogram (ECG) in patients with non-ST-elevation acute coronary syndrome and an elevated troponin T randomized to a selective invasive (SI) or an early invasive treatment strategy.


METHODS
A 12-lead ECG obtained at admission was available for analysis from 1163 patients. The presence and magnitude of ST-segment deviation was measured in each lead, and absolute ST-segment deviation was summed. The effect of treatment strategy was assessed for patients with or without SigmaST-segment deviation of at least 1 mm.


RESULTS
The incidence of death or myocardial infarction (MI) by 1 year in patients with SigmaST-segment deviation of at least 1 mm was 18.0% compared with 11.1% in patients with SigmaST-segment deviation of less than 1 mm (P = .001). Among patients with SigmaST-segment deviation of at least 1 mm, the incidence of death or MI was 21.9% in the early invasive group compared with 14.2% in SI group (P < .01). However, we observed a significantly higher rate of MI after hospital discharge among patients with SigmaST-segment deviation of at least 1 mm randomized to SI who did not undergo angiography compared with patients who underwent angiography before discharge (10.9% vs 2.4%, P = .003). In a forward logistic regression analysis, the presence of ST-segment deviation was an independent predictor for failure of medical therapy (coronary angiography within 30 days after randomization in the SI group) (odds ratio, 1.56; 95% confidence interval, 1.12-2.18; P = .009).


CONCLUSIONS
Patients with non-ST-elevation acute coronary syndrome and an elevated troponin T and SigmaST-segment deviation of at least 1 mm are at increased risk of death or MI, more often fail on medical therapy, and more often experience a spontaneous MI after discharge when angiography was not performed during initial hospitalization.
Windhausen
Fons
F
Department of Cardiology of the Academic Medical Center, Amsterdam, The Netherlands. a.windhausen@amc.uva.nl <a.windhausen@amc.uva.nl>
Hirsch
Alexander
A
Tijssen
Jan G P
JG
Cornel
Jan Hein
JH
Verheugt
Freek W A
FW
Klees
Margriet I
MI
de Winter
Robbert J
RJ
D000208:Acute Disease; D000789:Angina, Unstable / Q000097:blood / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D015906:Angioplasty, Balloon, Coronary / Q000401:mortality; D002316:Cardiotonic Agents / Q000627:therapeutic use; D004562:Electrocardiography / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D009426:Netherlands; D017063:Outcome Assessment, Health Care / Q000379:methods; D015995:Prevalence; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D015996:Survival Rate; D013577:Syndrome; D016896:Treatment Outcome; D019210:Troponin I / Q000097:blood
D002316:Cardiotonic Agents; D019210:Troponin I