title: Influence of presenting electrocardiographic findings on the treatment and outcomes of patients with non-ST-segment elevation myocardial infarction.
abstract: The influence of the presenting electrocardiographic (ECG) findings on the treatment and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI) has not been studied in contemporary practice. We analyzed the clinical characteristics, in-hospital management, and in-hospital outcomes of patients with NSTEMI in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (ACTION Registry-GWTG) according to the presenting ECG findings. A total of 175,556 patients from 485 sites from January 2007 to September 2011 were stratified by the ECG findings on presentation: ST depression (n = 40,146, 22.9%), T-wave inversions (n = 24,627, 14%), transient ST-segment elevation (n = 5,050, 2.9%), and no ischemic changes (n = 105,733, 60.2%). Patients presenting with ST-segment depression were the oldest and had the greatest prevalence of major cardiac risk factors. Coronary angiography was performed most frequently in the transient ST-segment elevation group, followed by the T-wave inversion, ST-segment depression, and no ischemic changes groups. The angiogram revealed that patients with ST-segment depression had more left main, proximal left anterior descending, and 3-vessel coronary artery disease and underwent coronary artery bypass grafting most often. In contrast, patients with transient ST-segment elevation had 1-vessel CAD and underwent percutaneous coronary intervention the most. The unadjusted mortality was highest in the ST-segment depression group, followed by the no ischemic changes, transient ST-segment elevation, and T-wave inversion group. Adjusted mortality using the ACTION Registry-GWTG in-hospital mortality model with the no ischemic changes group as the reference showed that in-hospital mortality was similar in the transient ST-segment elevation (odds ratio 1.15, 95% confidence interval 0.97 to 1.37; p = 0.10), higher in the ST-segment depression group (odds ratio 1.46, 95% confidence interval 1.37 to 1.54; p <0.0001), and lower in the T-wave inversion group (odds ratio 0.91, 95% confidence interval 0.83 to 0.99; p = 0.026). In conclusion, the clinical and angiographic characteristics and treatment and outcomes of patients with NSTEMI differed substantially according to the presenting ECG findings. Patients with ST-segment depression have a greater burden of co-morbidities and coronary atherosclerosis and have a greater risk of adjusted in-hospital mortality compared with the other groups. These findings highlight the importance of integrating the presenting ECG findings into the risk stratification algorithm for patients with NSTEMI.
authors.affiliation: Cardiovascular Section, Department of Medicine, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.
authors.forename: Jigar H
authors.initials: JH
authors.lastname: Patel
authors.affiliation: Cardiovascular Section, Department of Medicine, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.
authors.forename: Raghav
authors.initials: R
authors.lastname: Gupta
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: S Andrew
authors.initials: SA
authors.lastname: Peng
authors.affiliation: Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Wiviott
authors.affiliation: Cardiovascular Section, Department of Medicine, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma. Electronic address: jorge-saucedo@ouhsc.edu.
authors.forename: Jorge F
authors.initials: JF
authors.lastname: Saucedo
mesh_terms: D000368:Aged; D017023:Coronary Angiography; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000503:physiopathology* / Q000601:surgery; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology