Clinical investigations
Dynamic prognostication in non-ST–elevation acute coronary syndromes: insights from GUSTO-IIB and pursuit

https://doi.org/10.1016/j.ahj.2003.05.004Get rights and content

Abstract

Background

Risk assessment in patients with non-ST–elevation acute coronary syndromes (NSTE-ACS) traditionally focuses on and is limited to admission findings. The objective of the current study was to develop an approach to predicting outcome in NSTE-ACS that could account for the changing nature of risk.

Methods

In 7294 of 8010 patients with NSTE-ACS and complete electrocardiographic data in the GUSTO-IIb trial, we predicted the mortality probability at days 0–2, 0–30, 3–30, 5–30, and 7–30 using multiple logistic regression. Resulting risk estimates were incorporated into a composite, dynamic model to estimate the effects of changing probabilities over time. These models were validated against an independent sample of 9461 patients from the PURSUIT trial.

Results

As time passed after admission, the risk of 30-day death declined in stable patients. This risk, which was 3.72% at baseline, declined to 1.92% in 6-day survivors, and the risk reduction was greatest for those with the highest baseline risk. Importantly, however, the development of inhospital complications modified these trends. The use of dynamic models not only allowed us to estimate early (<48 h) mortality with a high degree of accuracy (C-index of 0.87), but also to continuously update the longer-term prognosis with increasing accuracy: the C-index increased from 0.75 for the day 0–30 model to 0.81 and 0.82 for the composite and day 7–30 models, respectively.

Conclusions

Dynamic risk assessment is feasible and reliable. This approach can improve risk assessment and provide valuable guidance for management of patients with NSTE-ACS.

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.

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