title: Recurrent ischemia across the spectrum of acute coronary syndromes: prevalence and prognostic significance of (re-)infarction and ST-segment changes in a large contemporary registry.
abstract: BACKGROUND
  There are limited recent data on the prevalence and potentially different adverse impact of the various types of recurrent ischemia (RI) in unselected patients with acute coronary syndromes(ACS). We examined the clinical features and treatment associated with, and the differential prognostic impact of, the various types of RI in unselected patients across the broad spectrum of ACS in the contemporary era.
  
  
  METHODS
  The Global Registry of Acute Coronary Events (GRACE) was a prospective, multinational registry of patients hospitalized for ACS. Data were collected on standardized case report forms.
  
  
  RESULTS
  Of the 29,400 ACS patients enrolled in May 2000-March 2007, 21% developed RI; 2.4%, 4.9%, and 16% had myocardial (re-)infarction [(re-)MI], RI with ST-segment changes, and RI without ST-segment changes (not mutually exclusive), respectively. Rates of in-hospital mortality and complications, and 6-month mortality were significantly higher among patients with RI compared to those without; the rates were highest for patients who developed (re-)MI, followed by those with RI and ST-segment changes. After adjusting for other validated prognosticators in the GRACE risk score, all three types of RI retained an independent association with both higher in-hospital and post-discharge 6-month mortality. Early revascularization was associated with lower in-hospital mortality only in the group with (re-)MI (P for interaction=0.003).
  
  
  CONCLUSIONS
  Despite the current use of intensive medical therapies, RI remains a common and serious consequence across the spectrum of ACS. Different types of RI confer a variable adverse prognostic impact. Re-MI is associated with the worst outcome, which appears to be mitigated by early revascularization. Our findings underscore the persistent need to improve the treatment of ACS.
authors.affiliation: Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. yana@smh.toronto.on.ca
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
authors.forename: Philippe Gabriel
authors.initials: PG
authors.lastname: Steg
authors.forename: Gordon
authors.initials: G
authors.lastname: Fitzgerald
authors.forename: Laurent J
authors.initials: LJ
authors.lastname: Feldman
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.forename: Joel M
authors.initials: JM
authors.lastname: Gore
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Anderson
authors.forename: Jose
authors.initials: J
authors.lastname: López-Sendón
authors.forename: Enrique P
authors.initials: EP
authors.lastname: Gurfinkel
authors.forename: David
authors.initials: D
authors.lastname: Brieger
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000453:epidemiology*; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000453:epidemiology*; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000453:epidemiology; D015995:Prevalence; D011379:Prognosis; D012008:Recurrence; D012042:Registries