PROGNOSTIC VALUE OF CLINICAL MARKERS OF REPERFUSION IN PATIENTS WITH ACUTE MYOCARDIAL-INFARCTION TREATED BY THROMBOLYTIC THERAPY

Patients who cannot be reperfused after thrombolytic therapy have a hi gh mortality rate. Noninvasive clinical markers of reperfusion have be en widely studied, yet their prognostic significance remains unclear. To assess the prognostic value of commonly used noninvasive clinical m arkers of early reperfusion we studied 327 patients who received intra venous thrombolytic treatment (1.5 MU streptokinase in 1 hour or 100 m g alteplase in 3 hours) within 6 hours of acute infarction. Successful clinical reperfusion (SCR) was defined as the presence of at least tw o of the following criteria at 2 hours after thrombolytic treatment: ( 1) significant relief of pain (a 5-point reduction on a 1 to 10 subjec tive scale), (2) greater than or equal to 50% reduction of sum of ST s egment elevation, and (3) abrupt initial increase of creatine kinase l evels (more than twofold over the upper-normal or baseline elevated va lues). Clinical variables that were significantly associated by univar iate analysis were rested by multivariate analysis to obtain independe nt predictors of 30-day mortality rate. SCR was present in 210 (64%) p atients (group 1), and absent in 117 (36%) patients (group 2). The gro ups were similar for most baseline characteristics, although group 2 p atients were slightly older (mean 60 vs 57 years, p < 0.02). Thirty-da y outcomes for group 2 patients compared with group 1 patients were he art failure in 23.1% and 10.5% (p < 0.005), progression to cardiogenic shock in 12.8% and 0.5%, (p < 0.00001), and death in 16.2% and 3.8% ( p < 0.0001), respectively. By multivariate analysis the Killip class a t admission (p < 0.00001), the absence of SCR (p = 0.017), anterior in farct location (p = 0.021), and age (p = 0.03) were independent predic tors of mortality rate, and sex (p = 0.051) had borderline significanc e. The absence of SCR defined a group of patients with significantly h igher mortality rate (odds ratio 4.89, 95% confidence interval 2.07 to 11.57). Three simple noninvasive clinical criteria of successful repe rfusion may be used to identify a group of patients with poor prognosi s after thrombolytic therapy in whom alternative strategies could be a pplied.