Clinical investigationsDynamic prognostication in non-ST–elevation acute coronary syndromes: insights from GUSTO-IIB and pursuit☆
Section snippets
Patients
Our development cohort comprised all 8010 patients with NSTE-ACS enrolled in the Global Use of Strategies To Open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial. This trial enrolled 12,142 patients with (ST- or non-ST–elevation) acute myocardial infarction (MI) or unstable angina from May 19, 1994 to October 17, 1995 at 373 hospitals in 13 countries to compare the efficacy of hirudin versus heparin.8, 9 A blinded events committee classified 3517 patients as having NSTE-MI at
Events and interventions
Most complications occurred within the first few days (Table I). The median times to recurrent ischemia and the composite of serious complications were 1.8 and 3.3 days, respectively. The median time to bypass surgery was more than double that to emergency angiography and percutaneous intervention. The risk of death declined from 0.9% within 48 hours to 0.5%, and to 0.4% in the next two 48-hour periods among those who survived to the start of these periods.
Baseline and inhospital predictors of mortality
Age, systolic blood pressure, ST
Discussion
The principal novel finding of our study is that risk estimates can be updated over time in patients with NSTE-ACS, yielding highly accurate predictions of outcome. This concept is intrinsically attractive in practice because clinicians can readily recognize the difference in expected outcome when a patient admitted with stable hemodynamics suddenly develops hypotension and pulmonary edema. These models provide a basis for quantitative assessment of outcome that more closely approximates
Acknowledgements
We thank Ms Karen Pieper and Dr Andrew Allen of the Duke Clinical Research Institute and Dr Butch Tsiatis of North Carolina State University for their helpful comments on statistical methods, and Ms Patricia French for her editorial assistance.
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Guest Editor for this manuscript was Elliott M. Antman, MD, Brigham and Women's Hospital, Boston, Mass.