1. European Heart Association Journal 2007 April
Emergency Medicine
R3 김현진

2. Introduction
In 2000, The Joint European Society of Cardiology/American College of Cardiology (ESC/ACC) Committee for the redefinition of myocardial infarction
suggested that any amount of necrosis resulting from ischaemia should be diagnosed as a myocardial infarction
Unstable angina -> MI
Higher level of troponin : associated with more severe prognosis

3. The aim of this study
To describe MI patients’ in-hospital and long-term management and their clinical outcomes and to identify independent predictors of death

4. Methods : Inclusion criteria
18 years 이상
hospitalized for a myocardial infarction [defined as a rise in cardiac enzyme concentrations (TN- I and/or T, and/or CK-MB) according to the local hospital’s standard in the first 24 h]
And have the diagnosis of myocardial infarction confirmed at discharge

5. Results : study population
OPERA study
56 centres in France
October 2002 ~ September 2003
2151 consecutive patients (76.0% men) with myocardial infarction

8. Results : study population
Almost half (48.1%)
new or old Q-wave myocardial infarction
One-fifth (19.8%)
left-ventricular dysfunction (LVEF 40%)
The median time between symptom onset and arrival at hospital : 6 h
shorter with STEMI vs. with NSTEMI (4 vs. 7 h, P ,0.0001).
The mean length of hospitalization
days

9. Results : In-hospital treatments

10. Results : Treatments at 12 months following discharge

11. Results : In-hospital and post-discharge outcomes

12. Results : One year Kaplan-Meier survival curves STEMI vs. NSTEMI

13. Results : Independent predictors of in-hospital mortality

14. Results : Independent predictors of 1 year post-discharge mortality

15. Discussion The results of our study
patients with STEMI, who benefit most from reperfusion therapy (fibrinolytic drug or primary PCI) soon after the onset of symptoms, still delay presentation to hospital by 4 h
The rates of the use of aspirin at admission
lower (87 vs. 91%) than those reported in the Global Registry of Acute Coronary Events (GRACE)
increased to 91% for STEMI and 86% for NSTEMI by the time of discharge

16. Discussion Statin the strongest predictor of in-hospital death
less than half : given a statin at admission
80% : one at hospital discharge
83% : statin at 1 year follow-up.
the strongest predictor of in-hospital death
untreated dyslipidaemia
advanced age, diabetes, and low blood pressure on admission
independent predictors of in-hospital death

17. Discussion the strongest independent predictor of 1 year mortality
history of heart failure, advanced age, untreated dyslipidaemia, diabetes, increased heart rate, low blood pressure on admission
Treatment with statin
associated with a lower risk of in-hospital and 1 year death compared with no dyslipidaemia
also for the STEMI subgroup
Support to early and continuing treatment

18. Are patients with STEMI very different from those with NSTEMI?
The same pathophysiological process
The same treatments to prevent plaque rupture
In this study, the presence of ST-elevation
drives the decision to proceed to rapid reperfusion therapy
prescription at discharge of cardiac medications favored patients with STEMI
The baseline characteristics of the two subgroups differed
NSTEMI patients being older and at higher risk of recurrent ischemic events
also at greater risk of death following discharge

19. Are patients with STEMI very different from those with NSTEMI?
The cumulative in-hospital to 1 year post-discharge mortality
did not differ between the two groups
The annual rates of angioplasty and revascularization & the strongest predictors of death
similar between STEMI and NSTEMI
These findings support the new ESC/ACC definition of myocardial infarction, which combines STEMI with NSTE-ACS and elevated troponin

20. Conclusions patients with NSTEMI and STEMI
have comparable in-hospital and long-term prognoses
also have similar independent correlates of adverse outcome
These findings support the new ESC/ACC definition of myocardial infarction, which combines STEMI with NSTE-ACS and elevated troponin
STEMI and NSTEMI patients are treated differently in terms of coronary reperfusion but more surprisingly also in terms of secondary prevention

21. Conclusions
Compared with STEMI, patients with NSTEMI appear to be undertreated after discharge from hospital despite having a higher risk profile
The common definition and similar prognosis of patients with STEMI or NSTEMI should lead to more similar secondary prevention therapies to avoid recurrent ischemic events