Long-term prognostic value of ST-segment resolution in patients treated with fibrinolysis or primary percutaneous coronary intervention results from the DANAMI-2 (DANish trial in acute myocardial infarction-2).
OBJECTIVE
The purpose of this study was to determine the prognostic value of ST-segment resolution after primary percutaneous coronary intervention (pPCI) versus fibrinolysis.


BACKGROUND
Resolution of the ST-segment has been used as a surrogate end point in trials evaluating reperfusion in acute myocardial infarction; however, its prognostic significance may be limited to patients treated with fibrinolysis.


METHODS
In the DANAMI-2 (DANish trial in Acute Myocardial Infarction-2) substudy, including 1,421 patients, the ST-segment elevation at baseline, pre-intervention, 90 min, and 4 h was assessed. The ST-segment resolution was grouped as follows: 1) complete > or =70%; 2) partial 30% to <70%; and 3) no resolution <30%. End points were 30-day and long-term mortality and reinfarction.


RESULTS
The ST-segment resolution at 90 min was more pronounced after pPCI (median 60% vs. 45%, p < 0.0001), and a catch-up phenomenon was observed at 4 h. In the fibrinolysis group, 30-day and long-term mortality rates were significantly higher among patients without ST-segment resolution, whereas reinfarction rates were higher with complete ST-segment resolution. The ST-segment resolution was not associated with the 2 end points in the pPCI group. By multivariate analysis, ST-segment resolution at 4 h was an independent predictor of lower mortality, but higher reinfarction rates among patients receiving fibrinolytic therapy.


CONCLUSIONS
The ST-segment resolution at 90 min was more complete after pPCI, suggesting better epicardial and microvascular reperfusion, whereas no difference between treatment strategies was seen at 4 h. The ST-segment resolution at 4 h correlated with decreased mortality, but increased reinfarction rates among patients receiving fibrinolytic therapy, whereas no association was seen for patients receiving pPCI. Consequently, 4-h ST-segment resolution remains an important prognosticator after fibrinolysis, but may be overemphasized as a surrogate end point after pPCI.
Sejersten
Maria
M
Heart Center, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Faculty of Health Sciences, Copenhagen, Denmark. msejersten@hotmail.com
Valeur
Nana
N
Grande
Peer
P
Nielsen
Torsten Toftegaard
TT
Clemmensen
Peter
P
D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D015986:Confounding Factors, Epidemiologic; D003718:Denmark; D004562:Electrocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006329:Heart Conduction System / Q000187:drug effects / Q000503:physiopathology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011237:Predictive Value of Tests; D011379:Prognosis; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000379:methods; D013997:Time Factors
D005343:Fibrinolytic Agents