Time-based risk assessment after myocardial infarction. Implications for timing of discharge and applications to medical decision-making

Aims We evaluated timing of adverse cardiac events after thrombolysis to guide length of stay after ST-segment elevation myocardial infarction. Methods and Results Kaplan–Meier survival curves described timing of major postinfarction complications in 41021 fibrinolytic-treated patients in GUSTO-I. U...

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Bibliographic Details
Published in:European heart journal 2003-01, Vol.24 (2), p.182-189
Main Authors: Newby, L.K, Hasselblad, V, Armstrong, P.W, Van de Werf, F, Mark, D.B, White, H.D, Topol, E.J, Califf, R.M
Format: Article
Language:English
Subjects:
acute myocardial infarction
Biological and medical sciences
Cardiology. Vascular system
Coronary heart disease
Decision Making
Early discharge
Heart
Humans
Length of Stay
Medical sciences
Middle Aged
Myocardial Infarction - mortality
Myocardial Infarction - therapy
Myocarditis. Cardiomyopathies
Patient Discharge
Prognosis
Proportional Hazards Models
Risk Assessment
Risk Factors
Survival Analysis
survival modelling
Survival Rate
Thrombolytic Therapy - methods
Thrombolytic Therapy - mortality
Time Factors
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Summary:Aims We evaluated timing of adverse cardiac events after thrombolysis to guide length of stay after ST-segment elevation myocardial infarction. Methods and Results Kaplan–Meier survival curves described timing of major postinfarction complications in 41021 fibrinolytic-treated patients in GUSTO-I. Using model-fitting, these data were best explained by a mixed-exponential survival model: an acute curve describing most adverse events and a chronic curve describing a lower background rate. We replicated this strategy in 15059 fibrinolytic-treated patients in GUSTO-III. From the relation between time and events described by the model’s acute curve in GUSTO-III, we proposed times for hospital discharge. The acute curve explained 97% of deaths and 68%–96% of various event composites. Of complications within 10 days, 90% of deaths and 70% of acute curve death, stroke, shock, heart failure, or reinfarction occurred by 24 h. By 2.7 days, 95% of deaths, stroke, shock, heart failure, or reinfarction occurred. Most major ventricular arrhythmias occurred within 24 h, after which the hazard curve was flat. Conclusions Mixed-exponential survival modelling describes timing of post-infarction complications and supports discharge 4 days after uncomplicated infarction. Such time-based risk assessment could guide decision-making in other settings in which randomized studies are impractical.
ISSN:0195-668X
1522-9645
DOI:10.1016/S0195-668X(02)00301-9