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Clinical Guideline: Part II: Risk Stratification after Myocardial Infarction

Eric D. Peterson, MD, MPH; Leslee J. Shaw, PhD; and Robert M. Califf, MD
[+] Article, Author, and Disclosure Information

From Duke University Medical Center, Durham, North Carolina. Acknowledgment: The authors thank Patricia Williams for editorial assistance. Requests for Reprints: Eric D. Peterson, MD, MPH, Duke Clinical Research Institute, Bay A-1, 2024 West Main Street, Durham, NC 27705. Current Author Addresses: Drs. Peterson and Califf: Duke Clinical Research Institute, Bay A-1, 2024 West Main Street, Durham, NC 27705.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;126(7):561-582. doi:10.7326/0003-4819-126-7-199704010-00012
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Purpose: To review the literature on risk stratification after acute myocardial infarction in the reperfusion era and to propose an algorithm for early and continual risk assessment.

Data Sources: A MEDLINE search of the English-language literature on humans was done using the terms myocardial infarction, prospective studies, and prognosis. This search was supplemented by narrowed searches for subheadings (such as cardiogenic shock, thrombolytic therapy, and stress testing) and surveys of references cited in review articles and book chapters.

Study Selection: Literature on prognosis and myocardial infarction published from 1981 to 1996 was considered. From the literature on stress testing methods, studies that enrolled patients before 1980, enrolled patients for indications other than myocardial infarction, tested patients more than 6 weeks after infarction, were missing outcome data, or had inadequate follow-up were excluded.

Data Extraction: Because too few randomized trials were available to allow the cross-comparison of risk-stratification methods, the available observational data were synthesized and supplemented with clinical judgments to produce recommendations.

Data Synthesis: Risk stratification must begin when acute myocardial infarction is diagnosed. High-risk patients (such as those with cardiogenic shock) and candidates for reperfusion therapy must be identified quickly if ideal emergency care is to be given. At specific points during hospitalization, specialized tests may be useful if they add incremental information to the results of clinical evaluations. High-risk patients who have complications after infarction or significant left ventricular dysfunction probably benefit from early angiography; patients without these conditions are at low risk for recurrent events and should have noninvasive stress testing for further risk stratification.

Conclusions: Physicians should continually reappraise risk throughout hospitalization to optimize both patient outcomes and cost containment.


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Figure 1.
Timing of death after myocardial infarction in Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries [GUSTO-I].[2]

Data from Kleiman et al. .

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Figure 2.
Flow diagram of risk stratification after myocardial infarction.

CCU = coronary care unit; CHF = congestive heart failure; LBBB = left bundle-branch block; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty; ST = ST-segment.

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Figure 3.
Flow diagram for predischarge risk stratification.

LVEF = left ventricular ejection fraction.

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Figure 4.
Prognostic importance of ejection fraction before discharge in patients treated with and without thrombolysis.dashed line[184][180]

Data on 6-month, all-cause mortality rates from the Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardio ( ) and on 1-year cardiac mortality rates from the Multicenter Post-Infarction Research Group (solid line) .

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Figure 5.
Survival curves for medical (solid line) and surgical (dashed line) treatment of acute myocardial infarction in patients with left ventricular dysfunction and no significant angina.[255]

Data from Yusuf et al. .

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