title: Prognostic utility of quantifying evolutionary ST-segment depression on early follow-up electrocardiogram in patients with non-ST-segment elevation acute coronary syndromes.
abstract: OBJECTIVE
  Although ST-segment depression (STD) on the admission electrocardiogram (ECG) confers adverse prognosis in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), the implications of STD on follow-up ECG remain uncertain. We determined the prognostic significance of STD on follow-up ECG performed within 12-24 h of admission and whether its quantitative evaluation can further refine risk stratification.
  
  
  RESULTS
  The admission and follow-up ECGs of 3877 patients in the SYNERGY trial were analysed for the presence (>or=1 mm) and extent (maximum magnitude on any single lead) of STD. Of the 1110 patients presenting with STD on admission, 534 (48.1%) with persistent STD at follow-up had higher mortality at 30 days (7.1 vs. 3.6%, P = 0.01) and 6 months (10.7 vs. 5.2%, P = 0.001) than those with normalized STD. Among 2767 patients without STD on admission, 174 (6.3%) developed new STD on follow-up ECG and experienced increased mortality compared with those without such interval change (30 days: 4.0 vs. 1.7%, P = 0.035; 6 months: 8.0 vs. 3.3%, P = 0.001). After adjustment for established clinical prognosticators and the extent of STD on admission, every 1 mm increment of STD on the follow-up ECG independently predicted a graded increase in 30-day mortality [hazards ratio (HR) = 1.60, 95% confidence interval (CI) = 1.29-1.98, P < 0.0001], and death/myocardial infarction at 30 days (HR = 1.19, 95% CI = 1.03-1.36, P = 0.017) and 6 months (HR = 1.17, 95% CI = 1.03-1.32, P = 0.016).
  
  
  CONCLUSIONS
  The magnitude of STD on a routine 12-24 h follow-up ECG provides incremental prognostic information beyond established clinical prognosticators and the extent of STD on admission. Incorporating a follow-up ECG and its quantitative evaluation for STD may further refine risk stratification of patients with NSTE-ACS.
authors.affiliation: Canadian Heart Research Centre and Division of Cardiology, St Michael's Hospital, University of Toronto, 30 Bond Street, Room 6-034 Queen, Toronto, ON, Canada M5B 1W8.
authors.forename: Raymond T
authors.initials: RT
authors.lastname: Yan
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Karen
authors.initials: K
authors.lastname: Pieper
authors.forename: Jie-Lena
authors.initials: JL
authors.lastname: Sun
authors.forename: Carl J
authors.initials: CJ
authors.lastname: Pepine
authors.forename: Luigi M
authors.initials: LM
authors.lastname: Biasucci
authors.forename: Dietrich C
authors.initials: DC
authors.lastname: Gulba
authors.forename: Jose
authors.initials: J
authors.lastname: Lopez-Sendon
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality; D000368:Aged; D016757:Death, Sudden, Cardiac / Q000453:epidemiology; D004562:Electrocardiography / Q000379:methods* / Q000401:mortality; D005260:Female; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality; D011379:Prognosis; D011446:Prospective Studies; D012008:Recurrence; D012307:Risk Factors