Death and nonfatal reinfarction within the first 24 hours after presentation with an acute coronary syndrome: Experience from GUSTO-IIb

Background A large proportion of deaths among patients with myocardial infa rction occurs within the first 24 hours after presentation. It is not clear whether this phenomenon is also true of patients without ST-segment elevat ion who may or may not have infarction at the time of presentation. Thrombi n activity may also be greatest during the first 24 hours after plaque rupt ure. Accordingly, this study was designed to examine the pattern of early i schemic events among patients with acute coronary syndromes and to determin e whether the direct thrombin inhibitor desirudin (r-hirudin) would be most effective during this period. Methods and Results Among the 11,142 patients enrolled in GUSTO-II, death o r (re)infarction occurred within 24 hours in 210 patients (1.7%), represent ing 19% of the 1135 deaths that had occurred by 30 days. Death or (re)infar ction occurred within 24 hours in 113 patients (2.7%) with ST-segment eleva tion and in 97 patients without ST-segment elevation (1.2%, P < .001), repr esenting 26% and 14% of the 30-day event rates, respectively, for the 2 enr ollment strata. Among patients with ST-segment elevation, most of these eve nts were deaths, whereas among patients without ST-segment elevation, most events were (re)infarctions. Death or (re)infarction by 24 hours occurred i n 80 (1.3%) patients treated with desirudin and 130 (2.1%) patients treated with heparin (P = .01). This finding predominantly consisted of prevention of death among patients with ST-segment elevation and of (re)infarction am ong patients without ST-segment elevation. Conclusions These findings have important implications for early triage of patients with acute coronary syndromes and for the development of new thera pies directed at stabilizing the unstable atherosclerotic plaque.