Long-Term Mortality of Patients Undergoing Cardiac Catheterization for ST-Elevation and Non-ST-Elevation Myocardial Infarction

Long-Term Mortality of Patients Undergoing CardiacCatheterization for ST-Elevation and Non–ST-Elevation

Myocardial InfarctionMark Y. Chan, MBBS, MHS; Jie L. Sun, MS; L. Kristin Newby, MD, MHS; Linda K. Shaw, MS;

Min Lin, PhD; Eric D. Peterson, MD, MPH; Robert M. Califf, MD;David F. Kong, MD; Matthew T. Roe, MD, MHS

Background—There are limited contemporary data comparing long-term outcomes after cardiac catheterization forST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI).

Methods and Results—We studied patients undergoing cardiac catheterization for STEMI (n�2413) and NSTEMI(n�1974) between 1999 and 2005 with at least 1 significant coronary lesion �75%. We compared adjusted mortalityrates over restricted time intervals and the differential impact of early revascularization on mortality stratified byST-elevation status. Between 1999 and 2007, 1274 patients died, with a median follow-up of 4 years. A piece-wiseanalysis showed a higher adjusted mortality risk for STEMI during the first 2 months (adjusted hazard ratio, 1.85; 95%confidence interval, 1.45 to 2.38) and a lower adjusted mortality risk for STEMI after 2 months (adjusted hazard ratio,0.68; 95% confidence interval, 0.59 to 0.83). Compared with late or no revascularization, early revascularization wasassociated with a lower adjusted risk of mortality for both STEMI (adjusted hazard ratio, 0.73; 95% confidence interval,0.58 to 0.90) and NSTEMI (adjusted hazard ratio, 0.76; 95% confidence interval, 0.65 to 0.89) (P for interaction�0.22).

Conclusions—Among a contemporary cohort of acute MI patients with significant coronary disease during cardiaccatheterization, STEMI was associated with a higher risk of short-term mortality, but NSTEMI was associated with ahigher risk of long-term mortality. Early revascularization was associated with a similar improvement in long-termoutcomes for both STEMI and NSTEMI. These data suggest that in clinical investigations of early revascularizationamong patients with NSTEMI, extended follow-up may be necessary to demonstrate treatment benefit. (Circulation.2009;119:3110-3117.)

Key Words: acute coronary syndrome � angioplasty � catheterization � coronary disease � electrocardiography� myocardial infarction � revascularization

Myocardial infarction (MI) remains a leading cause ofmortality worldwide.1 ST-elevation MI (STEMI) is

associated with a higher incidence of persistent and totalcoronary occlusion, whereas non-STEMI (NSTEMI) is asso-ciated with a greater severity and burden of coronary arterydisease (CAD).2 The contemporary definition of MI, intro-duced in 19993 and revised in 20074, focused on circulatingbiomarkers, predominantly troponin, that detect myocardialnecrosis with high sensitivity. However, most of the priorstudies that investigated long-term outcomes on the basis ofMI classification focused on non–Q-wave MI versus Q-waveMI comparisons,5–20 whereas fewer contemporary studieshave used the newer troponin-based MI definition and clas-sification system (STEMI versus NSTEMI).21–24

Clinical Perspective on p 3117

Several other potential differences exist between patientsin current practice and those in historical studies. In contem-porary practice, the diagnosis is often based on a history ofchest pain and elevated biomarkers rather than ECG find-ings.25–27 In contrast, several historical studies specifiedST-segment depression and T-wave inversion as major diag-nostic criteria for non–Q-wave MI.11,17 An increasing numberof patients with NSTEMI in contemporary practice havereceived treatment with evidence-based medications and haveundergone coronary revascularization before presenta-tion.23,28 Because recent data have shown a decline in the6-month mortality of patients with STEMI with no change in

Received June 19, 2008; accepted April 24, 2009.From the National University Heart Centre, Singapore, Singapore (M.Y.C.); Montreal Heart Institute, Montreal, Quebec, Canada (M.Y.C.); Duke

Clinical Research Institute, Durham, NC (J.L.S., L.K.N., L.K.S., M.L., E.D.P., D.F.K., M.T.R.); and Duke Translational Medicine Institute, Durham, NC(R.M.C.).

The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/CIRCULATIONAHA.108.799981/DC1.

Correspondence to Dr Mark Y. Chan, MBBS, MHS, National University Heart Center, 5 Lower Kent Ridge Road, Singapore, Singapore 119074.E-mail [email protected]

© 2009 American Heart Association, Inc.

Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.108.799981

3110 by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from

http://circ.ahajournals.org/











the mortality of patients with NSTEMI despite an increasinguse of cardiac catheterization and revascularization for bothtypes of patients, the long-term prognosis by MI classificationis uncertain in contemporary practice.28

Therefore, we identified patients with biomarker-definedacute MI who had least 1 significant coronary lesion duringcardiac catheterization to compare differences in long-termmortality between STEMI and NSTEMI. Additionally, weevaluated the differential impact of early revascularizationon the long-term mortality of patients with STEMI andNSTEMI.

MethodsWe performed a retrospective study of 4606 consecutive patientsundergoing diagnostic cardiac catheterization from 1999 to 2005 forthe indication of acute MI who were found to have at least 1significant coronary lesion �75% on angiography at the DukeUniversity Medical Center (Durham, NC). We relied on the treatingphysician’s diagnosis of MI without the use of central adjudication,including all patients �18 years of age with MI diagnosed on thebasis of a troponin T level �0.1 ng/mL, the decision limit in effectduring the study period, or creatine kinase-MB level �9 ng/mL, the99th percentile of a reference control population. We evaluated theindividual troponin and creatine kinase-MB measurements of allidentified subjects to confirm the presence of at least 1 elevatedbiomarker measurement during the index hospitalization. Classifica-tion of NSTEMI and STEMI was determined by the treatingphysician and based on interpretation of the ECG assessment ofthe patient’s clinical status. The cardiology fellow completing theelectronic case report form for each patient independently verified,using a computer-assisted quality-control feedback system, all clin-ical, ECG, and angiographic data, including the final diagnoses ofSTEMI and NSTEMI.

We excluded patients without troponin or creatine kinase MBdata, patients with incomplete angiograms, and to limit the contri-bution of nonvascular causes to overall mortality, patients withconditions likely to affect long-term survival independently ofcoronary disease (Figure 1).

Baseline characteristics, medical history, physical examination,initial cardiac catheterization results, and revascularization proce-dures performed within the first 30 days were collected prospectivelyas previously described.29,30 Severity of CAD was scored angio-graphically with the Duke CAD severity index31 (see the online-onlyData Supplement). All data were stored in the Duke Databank forCardiovascular Diseases. The Duke University Medical CenterInstitutional Review Board approved the study with waiver of therequirement for written informed consent.

OutcomesAs part of the standard follow-up for the Duke Databank forCardiovascular Diseases, all patients with a coronary lesion �75%on angiography were followed up at 6 months and annually there-after for mortality status by telephone contact, mailed questionnaire,and National Death Index search. Follow-up was considered com-plete if the mortality committee confirmed the patient’s death or ifthe patient was successfully contacted at the scheduled follow-upinterval. Follow-up for mortality status was 97% complete for allscheduled contacts as of December 1, 2007. All periprocedural andperioperative fatalities were counted as end points. Patients withincomplete follow-up were censored at the time of last contact.

Statistical MethodsAll statistical analyses were performed with SAS version 8.2 (SASInstitute Inc, Cary, NC). All probability values were 2 tailed with��0.05, and all confidence intervals (CIs) were calculated to the95th percentile. No adjustments were made for multiple compari-sons. Categorical data were displayed as proportions and continuousdata as medians and 25th to 75th percentiles. Comparison of baselinecharacteristics, angiographic results, revascularization rates, and medi-cation use between STEMI and NSTEMI patients was performed withthe Pearson �2 test for categorical variables, the 2-sample t test fornormally distributed continuous variables, and the Wilcoxonrank-sum test for nonnormally distributed data. To study theimpact of early revascularization in both STEMI and NSTEMIgroups, we stratified patients within each group into early andlate/no revascularization. Early revascularization was defined aspercutaneous coronary intervention (PCI)/coronary artery bypassgraft surgery (CABG) within 48 hours of admission; late revas-cularization was defined as PCI/CABG after 48 hours but within30 days of admission.

Survival by MI classification (STEMI versus NSTEMI) wasevaluated with the Kaplan–Meier method, and relative survival wascompared by use of Cox proportional hazards with stepwise andbackward variable selection methods. A value of P�0.05 was usedas the criterion for variables to remain in the model. Theproportional-hazards assumption was assessed with Schoenfeld re-siduals; the assumption of linearity was evaluated for continuousvariables with restricted cubic splines. When the relationship wasfound to be nonlinear, appropriate transformations were applied (seethe online-only Data Supplement). We analyzed MI classificationand baseline demographic, clinical, and angiographic variables ascovariates to determine the adjusted risk of long-term mortality witha median follow-up of 4 years. Because historical data on thedifferential survival in Q-wave versus non–Q-wave MI patients haveshown higher short-term mortality in Q-wave MI but higher long-term mortality in non–Q-wave MI,2 we included a 2-piecewiseproportional-hazards model that allowed us to stratify outcomes by 2time periods from the index catheterization: an early time period (0to 2 months) and a late time period (2 months to 8 years). The2-month time point was selected through visual assessment ofthe inflection point in the cumulative hazard function. To assessthe validity of using a piecewise model with a cut point at 2month, we reanalyzed the data using different cut points on eitherside of the 2-month cut point (range, 24 hours to 6 months).Because these sensitivity analyses consistently showed an earlyhazard with STEMI and late hazard with NSTEMI, only the2-month piecewise model is shown.

Because of a possible interaction between ST-segment elevationstatus and age and the presence of prior infarction,32 comparisonsbetween STEMI and NSTEMI were further stratified according tofirst MI or subsequent MI. Interaction terms between ST-segmentelevation status and the presence of diabetes, sex, and CAD indexalso were computed to assess whether a differential association ofST-segment elevation status with survival existed within thesesubgroups.

Finally, to study the impact of early revascularization on long-term outcomes, we determined the adjusted hazard ratio (HR) of

Figure 1. Patient flow. ACHD indicates adult congenital heartdisease.

Chan et al Mortality After Catheterization: STEMI vs NSTEMI 3111

by guest on May 24, 2016http://circ.ahajournals.org/Downloaded from


early revascularization versus late/no revascularization within theSTEMI and NSTEMI groups.

The authors had full access to and take full responsibility forthe integrity of the data. All authors have read and agree to themanuscript as written.

Results

Patient CharacteristicsDuring the 6-year patient accrual period (1999 to 2005), weidentified 4387 patients who met the eligibility criteria for the

study (Figure 1). A total of 1974 patients (45%) were classifiedby the treating physician as having STEMI, and 2413 patients(55%) were classified as having NSTEMI. On a yearly basis,the proportion of patients with NSTEMI increased and theproportion of patients with STEMI decreased (Figure 2).

Patients with NSTEMI were older, were more likely to bewomen, and had a greater burden of comorbidities (Table 1).Furthermore, patients with NSTEMI were more likely to haveleft main and multivessel coronary disease and higher leftventricular ejection fraction values compared with patientswith STEMI (Table 2). Patients with NSTEMI were morelikely to undergo CABG within 30 days of presentation,whereas patients with STEMI were more likely to undergoPCI. A total of 412 STEMI patients received fibrinolytictherapy; 83 had PCI for failed fibrinolysis or recurrentischemia within 24 hours of fibrinolysis, and the remainder ofpatients underwent nonurgent PCI without preceding recur-rent ischemia.

Mortality in the Overall Patient CohortOver a period of 8 years, 1274 patients died. Unadjustedmortality at 1 year was lower among STEMI patients thanNSTEMI patients (9.5% versus 14.3%, respectively), as waslong-term mortality (median 4-year follow-up, 28.9% versus44.9%, respectively). Visual assessment of the Kaplan–Meiercurves demonstrated an initially higher unadjusted mortalityrisk in STEMI patients followed by consistently higherunadjusted mortality after 2 months in NSTEMI patients(Figure 3). The long-term mortality difference persisted afteradjustment for baseline characteristics, clinical presentationfeatures, and angiographic disease severity, with an adjusted

0

20

40

60

80

100

1999 2000 2001 2002 2003 2004 2005Year

%

Figure 2. Proportion of STEMI vs NSTEMI patients over time.Light gray bars indicates patients with STEMI; black bars,patients with NSTEMI.

Table 1. Baseline Characteristics

STEMI (n�1974)NSTEMI

(n�2413) P

Demographics

Age, y 59 (51–69) 64 (56–74) �0.001

Men, % 68.7 64.8 0.006

Black, % 21.9 22.8 0.114

Medical history, %

Hypertension 57.1 71.7 �0.001

Diabetes mellitus 22.1 35.8 �0.001

Hyperlipidemia 41.9 57 �0.001

Family history ofCHD

27.2 36.8 �0.001

Current smoking 53.9 54.6 0.610

Prior heart failure 9.1 23.1 �0.001

Prior MI 12.0 20.1 �0.001

Prior PCI 11.6 19.6 �0.001

Prior CABG 22.9 24.3 0.286

Presentation features

GFR, mL/min 79.4 (62.7–95.3) 73.1 (53.5–90.1) �0.001

Charlson index* 0 (0–1) 1 (0–1) �0.001

Systolic BP 127 (113–144) 137.5 (122–157) �0.001

Heart rate, bpm 74 (65,87) 73 (64,83) �0.001

Killip class II–IV, % 29.1 1.2 �0.001

Peak troponin T,ng/mL

1.38 (0.4–3.97) 0.55 (0.22–1.32) �0.001

Peak CK-MB,ng/mL

50 (9–168) 16 (6–44) �0.001

CHD indicates coronary heart disease; GFR, glomerular filtration rate; BP,blood pressure; and CK-MB, creatine kinase MB. Continuous data areexpressed as medians (25th–75th percentiles).

*The Charlson index considers 12 chronic conditions and correspondingweights (range, 0 to 6) according to their association with 1-year mortality.33

Table 2. Catheterization Results and 30-DayRevascularization Status

STEMI(n�1974)

NSTEMI(n�2413) P

Angiographic findings

Left main disease* 10.8 23.1 �0.001

No. of diseased vessels* �0.001

1 44.5 31.7

2 27.9 25.1

3 27.6 43.3

Duke CAD index† 43 (31–71) 52 (31–91) �0.001

LVEF, %‡ 49 (39.7–57.8) 51.9 (40.1–61.1) �0.001

Early revascularization, %§ 74.9 56.0 �0.001

PCI performed within 30 dof catheterization, %

68.6 50.3 �0.001

CABG performed within 30 dof catheterization, %

16.9 20.0 �0.001

Continuous data are expressed as medians (25th–75th percentiles).*Significant disease is stenosis �75% in 1 coronary artery, except left main

disease (stenosis �50%).†The CAD index grades the severity and extent of CAD on a scale of 0 to 100

on the basis of the location and percentage stenosis of lesions and their relativeprognostic importance.31

‡Left ventricular ejection fraction (LVEF) as determined by biplane ventricu-lography using the modified area-length method.

§Defined as PCI or CABG within 48 hours of admission.

3112 Circulation June 23, 2009



HR of 0.84 (95% CI, 0.74 to 0.97; Table 3). Other covariatesretained in the final model are listed in the online-only DataSupplement.

Mortality Stratified by Time From CatheterizationThe piecewise model used to assess adjusted mortality over 2restricted time intervals, 0 to 2 months and 2 months to 8years, showed an inversion in the relative mortality risk overtime with a higher adjusted early mortality for STEMI(adjusted HR from 0 to 2 months, 1.85; 95% CI, 1.45 to2.38) and a lower adjusted late mortality for STEMI(adjusted HR from 2 months to 8 years, 0.68; 95% CI, 0.59to 0.83; Table 3).

Mortality Stratified by Use ofRevascularization ProceduresTable 4 compares the baseline and angiographic characteris-tics of patients undergoing early revascularization with thosereceiving late or no revascularization within 30 days. Com-pared with late or no revascularization, early revasculariza-tion was associated with an adjusted long-term mortalityhazard of 0.73 (95% CI, 0.58 to 0.90) for STEMI and 0.76(95% CI, 0.65 to 0.89) for NSTEMI (Table 3). There was nointeraction between early revascularization status and thedifferential long-term mortality among the STEMI versusNSTEMI groups (P for interaction�0.22).

Mortality Among SubgroupsIn a further analysis examining differential survival amongNSTEMI versus STEMI within several subgroups, we founda significant interaction of MI classification with age (P forinteraction�0.01) and CAD index (P for interaction�0.02)and a trend toward statistical significance for the interactionbetween MI classification and a history of prior MI (P forinteraction�0.09) (see Table 3) There was no significantinteraction of MI classification with sex (P for interac-tion�1.0) or a history of diabetes mellitus (P for interac-tion�0.5). Women had a higher long-term mortality thanmen within both the STEMI and NSTEMI groups (see the

Figure 3. Kaplan–Meier mortality curves of STEMI vs NSTEMIshowing all-cause mortality from the time of cardiaccatheterization.

Table 3. Unadjusted and Adjusted Outcomes

Patients,n

Deaths,n

HR (95% CI) forSTEMI vs NSTEMI

Long-term mortality: PH model

Unadjusted 4387 1274 0.57 (0.51–0.64)

Adjusted 4000 1172 0.84 (0.74–0.97)

Long-term mortality:piecewise model

Unadjusted 4387 1274

0–2 mo 1.14 (0.90–1.44)

2 mo–8 y 0.46 (0.40–0.53)

Adjusted 4000 1172

0–2 mo 1.85 (1.45–2.38)

2 mo–8 y 0.68 (0.59–0.83)

Early vs late/norevascularization: STEMI

Unadjusted 1974 441 0.52 (0.43–0.63)

Adjusted 1765 398 0.73 (0.58–0.90)*

Early vs late/norevascularization: NSTEMI

Unadjusted 2413 833 0.47 (0.41–0.53)

Adjusted 2235 774 0.76 (0.65–0.89)*

Age �70 y

Unadjusted 4387 1274 0.57 (0.49–0.67)

Adjusted 4000 1172 0.74 (0.62–0.88)†

Age �70 y

Unadjusted 4387 1274 0.79 (0.67–0.93)

Adjusted 4000 1172 1.02 (0.85–1.23)†

Men

Unadjusted 4387 1274 0.53 (0.45–0.61)

Adjusted 4000 1172 0.86 (0.73–1.02)‡

Women

Unadjusted 4387 1274 0.68 (0.56–0.81)

Adjusted 4000 1172 0.85 (0.70–1.04)‡

DM

Unadjusted 4387 1274 0.59 (0.48–0.72)

Adjusted 4000 1172 0.91 (0.73–1.14)§

No DM

Unadjusted 4387 1274 0.62 (0.54–0.72)

Adjusted 4000 1172 0.83 (0.71–0.98)§

Prior MI

Unadjusted 4387 1274 0.59 (0.45–0.78)

Adjusted 4000 1172 1.08 (0.81–1.42)�No prior MI

Unadjusted 4387 1274 0.59 (0.52–0.67)

Adjusted 4000 1172 0.82 (0.71–0.94)�Duke CAD index�median#

Unadjusted 4380 1271 0.62 (0.53–0.74)

Adjusted 4000 1172 0.72 (0.60–0.86)¶

Duke CAD index�median#

Unadjusted 4380 1271 0.65 (0.55–0.76)

Adjusted 4000 1172 1.00 (0.83–1.20)¶

PH indicates proportional hazards; DM, diabetes mellitus.Adjusted interaction P values for subgroup analyses: *early vs late/no

revascularization and STEMI vs NSTEMI, P�0.22; †STEMI vs NSTEMI and age,P�0.01; ‡STEMI vs NSTEMI and sex, P�1.0; §STEMI vs NSTEMI and diabetesmellitus, P�0.5; �STEMI vs NSTEMI and prior MI, P�0.09; ¶STEMI vs NSTEMIand Duke CAD index, P�0.02.

#The median (25th, 75th percentile) Duke CAD index was 52 (31, 77).




online-only Data Supplement). Within the STEMI group,women were less likely to undergo revascularization at 30days than men (81% versus 87.5%). Similarly, within theNSTEMI group, only 66% of women underwent revascular-ization within 30 days compared with 73% of men.

DiscussionAmong patients undergoing cardiac catheterization foracute MI defined with troponin-based criteria, STEMI wasassociated with a lower late mortality risk compared withNSTEMI. Although early (0 to 2 months) mortality washigher for STEMI, late (beyond 2 months) mortalityremained consistently lower for STEMI through 8 years offollow-up.

Comparisons With Prior StudiesAlthough the majority of studies point toward a similar orhigher long-term mortality with non–Q-wave MI comparedwith Q-wave MI,2 there are conflicting data on the prog-nosis of contemporary patients with STEMI versus

NSTEMI identified using the current consensus MI defi-nition.23,24 Our study showed that long-term mortality wasalmost 30% for STEMI and 45% for NSTEMI, a findingthat is consistent with other studies comparing long-termsurvival in Q-wave versus non–Q-wave MI in the prereper-fusion era.2

Reasons for Differences in OutcomesThere are several possible reasons for the time-dependentdifferences in outcomes among patients with STEMI andNSTEMI observed in our study. First, the greater preva-lence of comorbidities among patients with NSTEMIaccounts for much of the excess long-term mortality in thisgroup, as evidenced by substantial attenuation of the HRafter adjustment for differences in the composite Charlsoncomorbidity index and other comorbidities. Patients withNSTEMI have consistently been shown to receive fewerguideline-recommended medications on discharge com-pared with patients with STEMI,34 a discrepancy withpotentially greater impact on long-term outcomes than

Table 4. Baseline Characteristics Stratified by Early Revascularization Status

STEMI (n�1974) NSTEMI (n�2413)

Early Revascularization(n�1478)

Late*/No Revascularization(n�496)

Early Revascularization(n�1351)

Late*/No Revascularization(n�1062) P

Demographics

Age, y 58 (50–68) 63 (53–72) 62 (53–72) 68 (59–76) �0.001

Men, % 69.9 65.3 66.8 62.2 0.004

Black, % 20.2 27.0 21.5 24.3 0.002

Medical history, % �0.001

Diabetes mellitus 20.0 28.4 30.6 42.4 �0.001

Prior MI 10.3 17.1 16.7 24.3 �0.001

Prior heart failure 6.7 16.3 14.8 33.6

Prior PCI 10.1 16.1 19.3 20.1 �0.001

Prior CABG 17.5 39.1 19.8 30.0 �0.001

Presentation features

GFR, mL/min 80.7 (64.7–95.7) 74.7 (56.8–93.8) 77.4 (61.4–92.6) 66 (46.7–85.6) �0.001

Charlson index 0 (0–1) 0 (0–1) 0 (0–1) 1 (0–2) �0.001

Systolic BP, mm Hg 127 (113–143) 128 (113–144) 137 (121–155) 139 (122–159) �0.001

Heart rate, bpm 74 (65–86) 76 (67–89) 72 (63–81) 75 (66–86) �0.001

Killip class II–IV, % 34.5 20.6 1.5 0.7 �0.001

Angiographic findings

Left main disease 8.5 17.1 15.3 32.4 �0.001

Diseased vessels, n �0.001

1 50.7 26.2 41.7 18.9

2 28.9 24.8 29.0 20.1

3 20.4 49.0 29.3 61.0

Duke CAD index 39 (31–52) 65 (39–77) 43 (31–71) 77 (52–91) �0.001

LVEF, % 50.9 (42.4–58.5) 44.6 (34.3–54.7) 55.2 (44.4–62.8) 47.8 (34.6–58.9) �0.001

30-d Revascularization status 100 42.4 100 32.4 �0.001

GFR indicates glomerular filtration rate; BP, blood pressure; and LVEF, left ventricular ejection fraction. Continuous data are expressed as medians (25th–75thpercentiles).

*Defined as PCI/CABG beyond 48 hours but within 30 days of admission.




differences in early revascularization. Second, other inves-tigators have shown that patients with NSTEMI havehigher rates of recurrent ischemia and late mortality.35 Ourangiographic data showed that patients with NSTEMI hada greater prevalence of left main and double- and triple-vessel disease, as well as a higher Duke CAD index,compared with patients with STEMI. Although we did notassess recurrent ischemia, we hypothesize that the greaterCAD severity among NSTEMI patients compared withSTEMI patients may have led to more recurrent ischemia.

Third, early revascularization for STEMI and NSTEMIwas associated with lower long-term mortality, even afteradjustment for a comprehensive set of covariates. Althoughpatients with STEMI clearly benefit from early reperfusion,36

the benefit from early catheterization followed by earlyrevascularization among patients with NSTEMI has been lessconsistent26; the most recent randomized comparison of earlyinvasive management among patients with non–ST-elevationacute coronary syndrome, the Timing of Intervention inAcute Coronary Syndromes (TIMACS) trial, failed to showan improvement in the primary end point at 6 months in theoverall study population,37 although the early invasive strat-egy was associated with better outcomes among the highest-risk subgroup. Our nonrandomized study is the first to showa similar survival advantage with early revascularizationamong patients with STEMI and NSTEMI (P for interac-tion�0.22) over a median follow-up period of 4 years,indicating that among patients with NSTEMI, an extendedperiod of follow-up may be necessary to show a treatmenteffect in randomized trials investigating the early invasivestrategy.

Sex DifferencesA recent meta-analysis by O’Donoghue et al38 showed thatthe early invasive strategy did not benefit women withlow-risk NSTEMI, possibly because of an increased preva-lence of normal coronaries in this subgroup. Our study showsthat even among patients with acute MI and flow-limitingdisease on angiography, women were less likely than men toundergo revascularization at 30 days. Further research isneeded to better understand the physician and patientdecision-making process underlying this important treatmentdisparity. Moreover, the association between early revascu-larization and lower long-term mortality among the high-risktroponin-positive NSTEMI population in our study is consis-tent with the results of the TIMACS trial37 and the meta-anal-ysis by O’Donoghue et al,38 and supports the use of thisstrategy among high-risk patient subsets.

Study LimitationsOur study has several limitations. First, we evaluated onlyacute MI patients found to have significant CAD on angiog-raphy because longitudinal follow-up was available only forthese patients. Second, because the majority of STEMIpatients in our study received primary PCI and all patients inthe NSTEMI group underwent cardiac catheterization, sur-vival among both the STEMI and NSTEMI groups may be

better than that in an unselected acute MI population. Third,all patients were managed in a tertiary academic healthcaresetting in a single-center practice, so generalizability to thegeneral community is uncertain. Fourth, information ondischarge medications was lacking because of technicalproblems with extracting discharge medication lists before2002, so we could not ascertain how long-term secondaryprevention medications influenced mortality rates. Fifth, wecould not evaluate cause of death, so we could not delineatehow differences in cardiovascular versus noncardiovascularmortality rates influenced the overall mortality rates amongSTEMI versus NSTEMI. Finally, we did not account fordifferences in the success of PCI procedures among STEMIversus NSTEMI patients.

ConclusionsAmong patients with significant CAD found on angiographyfor acute MI identified by the use of a troponin-baseddefinition, STEMI was associated with a higher risk ofshort-term mortality compared with NSTEMI, but NSTEMIwas associated with a higher risk of long-term mortality.Early revascularization was associated with a similar reduc-tion in long-term mortality for both STEMI and NSTEMI.These data suggest that in clinical investigations of earlyrevascularization among patients with NSTEMI, measur-ing outcomes over an extended period of follow-up may benecessary to demonstrate a positive treatment effect.

AcknowledgmentWe would like to thank Emily Honeycutt for her help with databaseprogramming.

Source of FundingThis study was funded internally by the Duke Clinical ResearchInstitute, Durham, NC. Dr Chan receives salary support from theNational Medical Research Council, Singapore, Singapore, and theNational University Hospital, Singapore, Singapore; research supportfrom the Ralph Snyderman Foundation, Durham, NC, and the DukeClinical Research Institute, Durham, NC; and tuition fee and researchsupport from the Montreal Heart Institute, Montreal, Quebec.

DisclosuresDr Peterson holds research grants from Bristol Myers Squibb/Sanofi,Schering Plough, and Merck/Schering, The other authors report noconflicts.

References1. World Health Organization. Cardiovascular Diseases: Fact Sheet Number

317. Available at: http://www.who.int/mediacentre/factsheets/fs317/en/index.html. Accessed November 27, 2008.

2. Liebson PR, Klein LW. The non-Q wave myocardial infarction revisited:10 years later. Prog Cardiovasc Dis. 1997;39:399–444.

3. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarctionredefined: a consensus document of the Joint European Society ofCardiology/American College of Cardiology Committee for theRedefinition of Myocardial Infarction. J Am Coll Cardiol. 2000;36:959 –969.




4. Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myo-cardial Infarction. Universal definition of myocardial infarction. Cir-culation. 2007;116:2634 –2653.

5. Aguirre FV, Younis LT, Chaitman BR, Ross AM, McMahon RP, KernMJ, Berger PB, Sopko G, Rogers WJ, Shaw L, Knatterud G, BraunwaldE, for the TIMI II Investigators. Early and 1-year clinical outcome ofpatients’ evolving non-Q-wave versus Q-wave myocardial infarction afterthrombolysis: results from the TIMI II Study. Circulation. 1995;91:2541–2548.

6. Behar S, Haim M, Hod H, Kornowski R, Reicher-Reiss H, Zion M,Kaplinsky E, Abinader E, Palant A, Kishon Y, Reisin L, Zahavi I,Goldbourt U. Long-term prognosis of patients after a Q wave comparedwith a non-Q wave first acute myocardial infarction: data from theSPRINT Registry. Eur Heart J. 1996;17:1532–1537.

7. Benhorin J, Moss AJ, Oakes D, Marcus F, Greenberg H, Dwyer EM Jr,Algeo S, Hahn E. The prognostic significance of first myocardialinfarction type (Q wave versus non-Q wave) and Q wave location: theMulticenter Diltiazem Post-Infarction Research Group. J Am CollCardiol. 1990;15:1201–1207.

8. Goodman SG, Langer A, Ross AM, Wildermann NM, Barbagelata A,Sgarbossa EB, Wagner GS, Granger CB, Califf RM, Topol EJ, SimoonsML, Armstrong PW. Non-Q-wave versus Q-wave myocardial infarctionafter thrombolytic therapy: angiographic and prognostic insights from theglobal utilization of streptokinase and tissue plasminogen activator foroccluded coronary arteries, I: angiographic substudy. Circulation. 1998;97:444–450.

9. Krone RJ, Friedman E, Thanavaro S, Miller JP, Kleiger RE, Oliver GC.Long-term prognosis after first Q-wave (transmural) or non-Q-wave(nontransmural) myocardial infarction: analysis of 593 patients.Am J Cardiol. 1983;52:234–239.

10. Madias JE, Chahine RA, Gorlin R, Blacklow DJ. A comparison oftransmural and nontransmural acute myocardial infarction. Circulation.1974;49:498–507.

11. Nicod P, Gilpin E, Dittrich H, Polikar R, Hjalmarson A, Blacky AR,Henning H, Ross J Jr. Short- and long-term clinical outcome after Q waveand non-Q wave myocardial infarction in a large patient population.Circulation. 1989;79:528–536.

12. Rigo P, Murray M, Taylor DR, Weisfeldt ML, Strauss HW, Pitt B.Hemodynamic and prognostic findings in patients with transmural andnontransmural infarction. Circulation. 1975;51:1064–1070.

13. Stone PH, Raabe DS, Jaffe AS, Gustafson N, Muller JE, Turi ZG,Rutherford JD, Poole WK, Passamani E, Willerson JT. Prognostic sig-nificance of location and type of myocardial infarction: independentadverse outcome associated with anterior location. J Am Coll Cardiol.1988;11:453–463.

14. Welty FK, Mittleman MA, Lewis SM, Healy RW, Shubrooks SJ Jr,Muller JE. Significance of location (anterior versus inferior) and type(Q-wave versus non-Q-wave) of acute myocardial infarction in patientsundergoing percutaneous transluminal coronary angioplasty for postin-farction ischemia. Am J Cardiol. 1995;76:431–435.

15. Zareba W, Moss AJ, Raubertas RF. Risk of subsequent cardiac events instable convalescing patients after first non-Q-wave and Q-wave myo-cardial infarction: the limited role of non-invasive testing: the MulticenterMyocardial Ischemia Research Group. Coron Artery Dis. 1994;5:1009–1018.

16. Berger CJ, Murabito JM, Evans JC, Anderson KM, Levy D. Prognosisafter first myocardial infarction: comparison of Q-wave and non-Q-wavemyocardial infarction in the Framingham Heart Study. JAMA. 1992;268:1545–1551.

17. Furman MI, Dauerman HL, Goldberg RJ, Yarzebski J, Lessard D, GoreJM. Twenty-two year (1975 to 1997) trends in the incidence, in-hospitaland long-term case fatality rates from initial Q-wave and non-Q-wavemyocardial infarction: a multi-hospital, community-wide perspective.J Am Coll Cardiol. 2001;37:1571–1580.

18. Gibson RS. Clinical, functional, and angiographic distinctions between Qwave and non-Q wave myocardial infarction: evidence of spontaneousreperfusion and implications for intervention trials. Circulation. 1987;75(suppl):V-128–V-138.

19. Herlitz J, Karlson BW, Sjolin M, Lindqvist J. Ten year mortality insubsets of patients with an acute coronary syndrome. Heart. 2001;86:391–396.

20. Karlson BW, Herlitz J, Richter A, Hjalmarson A. Prognosis in acutemyocardial infarction in relation to development of Q waves. ClinCardiol. 1991;14:875–880.

21. Allen LA, O’Donnell CJ, Camargo CA Jr, Giugliano RP, Lloyd-JonesDM. Comparison of long-term mortality across the spectrum of acutecoronary syndromes. Am Heart J. 2006;151:1065–1071.

22. Cox DA, Stone GW, Grines CL, Stuckey T, Zimetbaum PJ, Tcheng JE,Turco M, Garcia E, Guagliumi G, Iwaoka RS, Mehran R, O’Neill WW,Lansky AJ, Griffin JJ. Comparative early and late outcomes after primarypercutaneous coronary intervention in ST-segment elevation and non-ST-segment elevation acute myocardial infarction (from the CADILLACtrial). Am J Cardiol. 2006;98:331–337.

23. Montalescot G, Dallongeville J, Van Belle E, Rouanet S, Baulac C,Degrandsart A, Vicaut E. STEMI and NSTEMI: are they so different? 1Year outcomes in acute myocardial infarction as defined by theESC/ACC definition (the OPERA registry). Eur Heart J. 2007;28:1409–1417.

24. Terkelsen CJ, Lassen JF, Norgaard BL, Gerdes JC, Jensen T, GotzscheLB, Nielsen TT, Andersen HR. Mortality rates in patients withST-elevation vs. non-ST-elevation acute myocardial infarction: obser-vations from an unselected cohort. Eur Heart J. 2005;26:18–26.

25. Roger VL, Killian JM, Weston SA, Jaffe AS, Kors J, Santrach PJ,Tunstall-Pedoe H, Jacobsen SJ. Redefinition of myocardial infarction:prospective evaluation in the community. Circulation. 2006;114:790–797.

26. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, CaseyDE Jr, Chavey WE 2nd, Fesmire FM, Hochman JS, Levin TN, LincoffAM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC Jr,Jacobs AK, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, LytleBW, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2007guidelines for the management of patients with unstable angina/nonST-elevation myocardial infarction. Circulation . 2007;116:e148 – e304.

27. Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A, Fernandez-Aviles F, Fox KA, Hasdai D, Ohman EM, Wallentin L, Wijns W.Guidelines for the diagnosis and treatment of non-ST-segment elevationacute coronary syndromes. Eur Heart J. 2007;28:1598–1660.

28. Fox KA, Steg PG, Eagle KA, Goodman SG, Anderson FA Jr, GrangerCB, Flather MD, Budaj A, Quill A, Gore JM. Decline in rates of deathand heart failure in acute coronary syndromes, 1999–2006. JAMA. 2007;297:1892–1900.

29. Califf RM, Harrell FE Jr, Lee KL, Rankin JS, Hlatky MA, Mark DB,Jones RH, Muhlbaier LH, Oldham HN Jr, Pryor DB. The evolution ofmedical and surgical therapy for coronary artery disease: a 15-yearperspective. JAMA. 1989;261:2077–2086.

30. Eisenstein EL, Shaw LK, Anstrom KJ, Nelson CL, Hakim Z, HasselbladV, Mark DB. Assessing the clinical and economic burden of coronaryartery disease: 1986–1998. Med Care. 2001;39:824–835.

31. Bart BA, Shaw LK, McCants CB Jr, Fortin DF, Lee KL, Califf RM,O’Connor CM. Clinical determinants of mortality in patients with angio-graphically diagnosed ischemic or nonischemic cardiomyopathy. J AmColl Cardiol. 1997;30:1002–1008.

32. Phibbs B, Marcus F, Marriott HJ, Moss A, Spodick DH. Q-wave versusnon-Q wave myocardial infarction: a meaningless distinction. J Am CollCardiol. 1999;33:576–582.

33. Sachdev M, Sun JL, Tsiatis AA, Nelson CL, Mark DB, Jollis JG. Theprognostic importance of comorbidity for mortality in patients with stablecoronary artery disease. J Am Coll Cardiol. 2004;43:576–582.

34. Roe MT, Parsons LS, Pollack CV Jr, Canto JG, Barron HV, Every NR,Rogers WJ, Peterson ED. Quality of care by classification of myocardialinfarction: treatment patterns for ST-segment elevation vs non-ST-segment elevation myocardial infarction. Arch Intern Med. 2005;165:1630–1636.

35. Armstrong PW, Fu Y, Chang WC, Topol EJ, Granger CB, Betriu A,Van de Werf F, Lee KL, Califf RM. Acute coronary syndromes in theGUSTO-IIb trial: prognostic insights and impact of recurrent ische-mia: the GUSTO-IIb Investigators. Circulation. 1998;98:1860 –1868.

36. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA,Halasyamani LK, Hochman JS, Krumholz HM, Lamas GA, Mullany CJ,Pearle DL, Sloan MA, Smith SC Jr, Anbe DT, Kushner FG, Ornato JP,Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, EttingerSM, Halperin JL, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B,Tarkington LG, Yancy CW. 2007 Focused update of the ACC/AHA 2004guidelines for the management of patients with ST-elevation myocardialinfarction. Circulation. 2008;117:296–329.

37. Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP,Afzal R, Chrolavicius S, Jolly SS, Widimsky P, Avezum A, RupprechtHJ, Zhu J, Col J, Natarajan MK, Horsman C, Fox KA, Yusuf S; TIMACS




Investigators. Early versus delayed invasive intervention in acutecoronary syndromes. N Engl J Med. 2009;360:2165–2175.

38. O’Donoghue M, Boden WE, Braunwald E, Cannon CP, Clayton TC, deWinter RJ, Fox KA, Lagerqvist B, McCullough PA, Murphy SA, Spacek

R, Swahn E, Wallentin L, Windhausen F, Sabatine MS. Early invasive vsconservative treatment strategies in women and men with unstable anginaand non–ST-segment elevation myocardial infarction: a meta-analysis.JAMA. 2008;300:71–80.

CLINICAL PERSPECTIVEIn this study of outcomes over a median follow-up period of 4 years among a contemporary cohort of patients undergoingcardiac catheterization for ST-elevation myocardial infarction (STEMI; n�1974) and non-STEMI (NSTEMI; n�2413) atan academic medical center, we compared mortality rates over restricted time intervals and the differential impact of earlyrevascularization on mortality stratified by ST-elevation status. The long-term mortality rates of 29% and 45% for STEMIand NSTEMI, respectively, remain very similar to historical mortality rates among patients with Q-wave and non–Q-waveMI in the era before reperfusion and early invasive therapy, indicating a critical need to develop more efficacious treatmentstrategies for both types of MI. The adjusted mortality risk was greater for STEMI during the first 2 months (hazard ratiofor STEMI versus NSTEMI, 1.85; 95% confidence interval, 1.45 to 2.38) but greater for NSTEMI after 2 months (hazardratio for STEMI versus NSTEMI, 0.68; 95% confidence interval, 0.59 to 0.83). Compared with late or no revascularization,early revascularization was associated with a lower adjusted risk of long-term mortality for both STEMI (hazard ratio, 0.73;95% confidence interval, 0.58 to 0.90) and NSTEMI (hazard ratio, 0.76; 95% confidence interval, 0.65 to 0.89) (P forinteraction�0.22). These data suggest that the relative mortality among patients managed invasively for STEMI andNSTEMI is time dependent, with NSTEMI imparting a delayed but substantial enhancement of mortality risk; moreover,early revascularization may improve very late survival to a similar extent for both infarct types. In clinical investigationsof early revascularization among patients with NSTEMI, extended follow-up may therefore be necessary to demonstratetreatment benefit.




M. Califf, David F. Kong and Matthew T. RoeMark Y. Chan, Jie L. Sun, L. Kristin Newby, Linda K. Shaw, Min Lin, Eric D. Peterson, Robert

and Non-ST-Elevation Myocardial InfarctionLong-Term Mortality of Patients Undergoing Cardiac Catheterization for ST-Elevation

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2009 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/CIRCULATIONAHA.108.799981

2009;119:3110-3117; originally published online June 8, 2009;Circulation.

http://circ.ahajournals.org/content/119/24/3110World Wide Web at:

The online version of this article, along with updated information and services, is located on the

http://circ.ahajournals.org/content/suppl/2009/06/08/CIRCULATIONAHA.108.799981.DC1.htmlData Supplement (unedited) at:

http://circ.ahajournals.org//subscriptions/

is online at: Circulation Information about subscribing to Subscriptions:

http://www.lww.com/reprints Information about reprints can be found online at: Reprints:

document. Permissions and Rights Question and Answer this process is available in the

click Request Permissions in the middle column of the Web page under Services. Further information aboutOffice. Once the online version of the published article for which permission is being requested is located,

can be obtained via RightsLink, a service of the Copyright Clearance Center, not the EditorialCirculationin Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions:


http://circ.ahajournals.org/content/119/24/3110

http://circ.ahajournals.org/content/suppl/2009/06/08/CIRCULATIONAHA.108.799981.DC1.html

http://www.ahajournals.org/site/rights/

http://www.lww.com/reprints

http://circ.ahajournals.org//subscriptions/


SUPPLEMENTAL MATERIAL Supplemental Methods Duke CAD Index The Duke CAD index, originally developed by David F. Kong, is an angiographic score that hierarchically assigns prognostic weights (0-100) based on the anatomic location, stenotic severity and extent of coronary artery lesions in an individual patient. The index reliably predicted 5-year mortality in an analysis of 3800 patients with native coronary artery disease1. The model was subsequently modified to predict long-term mortality among patients with coronary artery bypass graft disease2. To adjust for individual differences in the severity and extent of coronary artery disease, we used the latest iteration of this well-validated composite measure of angiographic disease burden as a covariate in all our multivariable models. As seen in the list of retained model covariates in the response to comment 1), the Duke CAD index was retained as a significant independent predictor in all four main effects models in our study. Duke CAD Index: Angiographic Scoring System

Adapted from Bart et al1.

Spline Transformations for Non-linear Continuous Variables: The following variables were each transformed to two linear splines since the linearity assumptions were not satisfied: SBP-right truncated at 125 mm Hg, HR-left truncated at 65 min-1, BMI-right truncated at 30 kg m-2, GFR-right truncated at 90 ml min-1, For each of these variables, the two linear splines were simplified to one piece if the other piece was not significant at the 0.05 level. Supplemental Tables Variable Retention in Multivariable Models: The following tables list the variables retained in the 4 main effects models: Long-term Propensity Hazards Model

Variable Dƒ Parameter Estimate SE

Chi-Square P value HR 95% CI

STEMI vs. NSTEMI

1 -0.17090 0.06768 6.3765 0.0116 0.843 0.738 0.962

Age, per decade increase

1 0.31235 0.02892 116.6595 <.0001 1.367 1.291 1.446

SBP, mm Hg* 1 -0.17405 0.02578 45.5827 <.0001 0.840 0.799 0.884Heart rate, min-1† 1 0.08801 0.00937 88.2721 <.0001 1.092 1.072 1.112BMI, kg m-2‡ 1 -0.04636 0.00802 33.3874 <.0001 0.955 0.940 0.970Charlson index 1 0.19546 0.02623 55.5208 <.0001 1.216 1.155 1.280Duke CAD index 1 0.00970 0.00134 52.3859 <.0001 1.010 1.007 1.012GFR, ml min-1§ 1 -0.16545 0.01429 134.0055 <.0001 0.848 0.824 0.872Black race 1 0.13877 0.07183 3.7323 0.0534 1.149 0.998 1.323Hyperlipidemia 1 -0.20046 0.06246 10.2988 0.0013 0.818 0.724 0.925Smoking 1 0.17940 0.06232 8.2871 0.0040 1.197 1.059 1.352Prior HF 1 0.40969 0.06854 35.7270 <.0001 1.506 1.317 1.723Prior CABG 1 -0.37495 0.07717 23.6051 <.0001 0.687 0.591 0.800Prior PCI 1 -0.18770 0.08091 5.3821 0.0203 0.829 0.707 0.971Hypertension 1 0.22592 0.07290 9.6047 0.0019 1.253 1.087 1.446 Dƒ =degrees of freedom, SE=standard error, HR=hazard ratio, CI=confidence interval,SBP=systolic blood pressure, BMI=body mass index, CAD= coronary artery disease, GFR=glomerular filtration rate, HF=heart failure, CABG=coronary artery bypass grafting, PCI=percutaneous coronary intervention.* per 10 mm Hg increase up to 125

mm Hg, †per 5 unit increase above 65 beats min-1, ‡per unit increase up to 30 kg m-2, §per 10 ml min-1 increase up to 90 ml min-1.

Piecewise Proportional Hazards Model

Variable Dƒ Parameter Estimate SE Chi-

Square P value HR 95% CI

STEMI vs. NSTEMI (0-2 months)

1 0.61638 0.12769 23.3006 <.0001 1.852 1.442 2.379

STEMI vs. NSTEMI (2mo-8 years)

1 -0.38305 0.07707 24.7034 <.0001 0.682 0.586 0.793

Age per decade increase, years

1 0.31168 0.02904 115.2179 <.0001 1.366 1.290 1.446

SBP, mm Hg 1 -0.17152 0.02582 44.1251 <.0001 0.842 0.801 0.886HR, min-1 1 0.08884 0.00933 90.7102 <.0001 1.093 1.073 1.113BMI 1 -0.04931 0.00798 38.1633 <.0001 0.952 0.937 0.967Charlson index 1 0.19109 0.02632 52.7004 <.0001 1.211 1.150 1.275Duke CAD index 1 0.00919 0.00133 47.6488 <.0001 1.009 1.007 1.012GFR, ml min-1 1 -0.16888 0.01429 139.7064 <.0001 0.845 0.821 0.869Black race 1 0.14063 0.07194 3.8209 0.0506 1.151 1.000 1.325Smoking 1 0.18424 0.06235 8.7315 0.0031 1.202 1.064 1.359Prior HF 1 0.40948 0.06837 35.8704 <.0001 1.506 1.317 1.722Prior CABG 1 -0.35512 0.07692 21.3120 <.0001 0.701 0.603 0.815Prior PCI 1 -0.23170 0.07987 8.4143 0.0037 0.793 0.678 0.928Hypertension 1 0.18853 0.07208 6.8407 0.0089 1.207 1.048 1.391

Early vs. Late/No Revascularization Model: STEMI

Dƒ Parameter

Estimate Chi-

Square P Value HR 95% CI

Early vs. late/no revascularization

1 -0.320 8.197 0.004 0.726 0.583 0.90


1 0.346 46.235 0.000 1.413 1.279 1.561

SBP, mm Hg 1 -0.230 40.888 0.000 0.794 0.740 0.852

HR min-1 1 0.083 33.721 0.000 1.087 1.057 1.118

BMI, kg m-2 1 -0.037 7.124 0.008 0.963 0.937 0.990

Charlson Index 1 0.251 23.840 0.000 1.285 1.162 1.421

Duke CAD Index 1 0.010 16.862 0.000 1.010 1.005 1.015

GFR, ml min-1 1 -0.157 35.962 0.000 0.854 0.812 0.899

Black race 1 0.040 0.098 0.754 1.041 0.811 1.335

Hyperlipidemia 1 -0.095 0.781 0.377 0.910 0.737 1.122

Smoking 1 0.183 2.733 0.098 1.201 0.967 1.493

Prior HF 1 0.323 5.658 0.017 1.381 1.059 1.803

Prior CABG 1 -0.398 8.643 0.003 0.672 0.515 0.876

Prior PCI 1 -0.222 2.023 0.155 0.801 0.589 1.088

Hypertension 1 0.345 8.901 0.003 1.411 1.125 1.770

Early vs. Late/No Revascularization Model: NSTEMI

Variable Dƒ Parameter Estimate SE

Chi-Square P value HR 95% CI

Early vs. late/no revascularization

1 -0.27518 0.07954 11.9684 0.0005 0.759 0.650 0.888


1 0.27725 0.03585 59.8036 <.0001 1.319 1.230 1.416

SBP, mm Hg 1 -0.12016 0.03849 9.7476 0.0018 0.887 0.822 0.956HR min-1 1 0.08641 0.01266 46.6011 <.0001 1.090 1.064 1.118BMI, kg m-2 1 -0.04768 0.01002 22.6387 <.0001 0.953 0.935 0.972Charlson index 1 0.17363 0.03129 30.7902 <.0001 1.190 1.119 1.265Duke CAD index 1 0.00742 0.00167 19.6381 <.0001 1.007 1.004 1.011GFR, ml min-1 1 -0.16606 0.01714 93.9223 <.0001 0.847 0.819 0.876Black race 1 0.11689 0.08931 1.7129 0.1906 1.124 0.944 1.339Hyperlipidemia 1 -0.24795 0.07665 10.4639 0.0012 0.780 0.672 0.907Smoking 1 0.20521 0.07618 7.2564 0.0071 1.228 1.057 1.425Prior HF 1 0.41116 0.08038 26.1651 <.0001 1.509 1.289 1.766Prior CABG 1 -0.41572 0.09482 19.2239 <.0001 0.660 0.548 0.795Prior PCI 1 -0.16810 0.09550 3.0980 0.0784 0.845 0.701 1.019Hypertension 1 0.11701 0.09360 1.5628 0.2113 1.124 0.936 1.350

Sex-specific Data: Baseline Characteristics:

STEMI (n=1974)

NSTEMI (n=2413)

Women (n=617)

Men (n=1357)

Women (n=819)

Men (n=1564)

P value

Demographics <0.001Age 65 (54,75 ) 57 (50,66 ) 68 (58,77 ) 63 (54,72 ) <0.001African -American 28.2 19.1 29.0 19.4 <0.001Medical History <0.001Diabetes Mellitus 26.4 20.1 42.9 31.9 <0.001Prior heart failure 10.8 8.4 24.8 22.2 <0.001Prior MI 10.9 12.5 15 22.8 <0.001Prior PCI 8.4 13.0 15.4 21.9 <0.001Prior CABG 17.8 25.3 19.3 27.0 <0.001Presentation Features

<0.001

GFR (ml/min) 69.9 (53.1,90.1) 82.2(67.9,96.6) 65.6(46.2,84.6) 76.8(58.7,92.4) <0.001Killip class II-IV, %

30.8 31 0.7 1.3 <0.001

Charlson index* 0.5 (0, 1) 0.4 (0, 1) 0.9 (0, 1) 0.8 (0, 1) <0.001Duke CAD severity index

43 (31, 65) 43 (31,71) 52 (31, 77) 65 (37, 91) <0.001

Ejection fraction, %

48.9 (38.5, 58.1) 49.1 (40.3, 57.5) 52.9 (41.8, 63.0)

51.2 (38.9, 60.2)

<0.001

30-day revascularization

81 87.5 66 72.6 <0.001

Long-Term Cumulative Survival Plots Stratified by Sex:

K-M Survival Curves: STEMI vs. NSTEMI Stratified by Sex

ST: Female ST: MaleNST: Female NST: Male

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Years0 1 2 3 4 5 6 7 8

References: 1. Bart BA, Shaw LK, McCants CB, Jr., Fortin DF, Lee KL, Califf RM, O'Connor

CM. Clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy. J Am Coll Cardiol. 1997;30:1002-1008.

2. Liao L, Kong DF, Shaw LK, Sketch MH, Jr., Milano CA, Lee KL, Mark DB. A

new anatomic score for prognosis after cardiac catheterization in patients with previous bypass surgery. J Am Coll Cardiol. 2005;46:1684-1692.

Documents

Long-Term Mortality of Patients Undergoing Cardiac Catheterization for ST-Elevation and Non-ST-Elevation Myocardial Infarction