25 June 2007
Patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) have similar prognoses, and similar correlates of adverse outcomes, report French researchers.
However, NSTEMI patients are less likely than STEMI patients to undergo reperfusion and to receive secondary prevention, say Gilles Montalescot (Pitié-Salpétrière University Hospital, Paris) and colleagues.
A European Society of Cardiology/American College of Cardiology(ESC/ACC) committee recently redefined MI to include any amount of necrosis resulting from ischemia, Montalescot et al explain in the European Heart Journal.
This means that patients who would previously have been diagnosed with unstable angina are now diagnosed with MI. Yet most registries analyze data for NSTEMI patients along with that for unstable angina patients and separately from STEMI patient data, the team notes.
As part of the OPERA study, the researchers described all acute MI patients’ in-hospital and long-term management and outcomes, taking the new definition into account.
A total of 2176 patients were diagnosed with MI at 56 centers in France. The majority (70.8%) were diagnosed with STEMI, and the remainder with NSTEMI. The median time between symptom onset and arrival at hospital was 6 hours and was shorter in patients with STEMI versus NSTEMI patients, at 4 versus 7 hours (p<0.0001).
STEMI patients were more likely to receive fibrinolysis (28.9% vs 0.7%, p<0.0001) and to undergo percutaneous coronary intervention (71.0% vs 51.6%, p<0.0001). Conversely, bypass surgery was performed more frequently in NSTEMI patients than STEMI patients(4.9% vs 3.1%, p<0.05).
STEMI patients were more likely than NSTEMI patients to receive aggressive secondary prevention therapies at discharge, which was not due to greater disease severity.
In-hospital mortality did not differ between STEMI and NSTEMI patients, at 4.6% versus 4.3%. Using follow-up data available for 1878 patients, the cumulative death rate at 1 year was 11.6% in patients with NSTEMI and 9.0% in those with STEMI. Again, the between-group difference was not significant.
Independent correlates of in-hospital mortality were untreated dyslipidemia, advanced age, diabetes, and low blood pressure, while the strongest predictors of 1-year mortality were heart failure and age.
The authors say their findings support the new ESC/ACC definition of MI, adding that “the common definition and similar prognosis of patients with STEMI or NSTEMI should lead to more similar secondary prevention therapies to avoid recurrent ischemic events.”
Christopher Bode and Andreas Zirlik (Medizinische Universitaetslinik, Freiburg, Germany) agreed with the team’s conclusions in an accompanying editorial.
They added that more aggressive in-hospital and secondary prevention strategies, particularly for the NSTEMI population, need to be confirmed in large, randomized, clinical outcome studies.
“Until proven otherwise, STEMI and NSTEMI are no identical twins, but equally dangerous,”
LINK: Eur Heart J 2007; 28: 1409-1417