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Prognostic Value of a Normal or Nonspecific Initial Electrocardiogram in Acute Myocardial Infarction
Robert D. Welch, MD;
Robert J. Zalenski, MD;
Paul D. Frederick, MPH, MBA;
Judith A. Malmgren, PhD;
Scott Compton, PhD;
Mary Grzybowski, PhD, MPH;
Sophia Thomas, MD;
Terry Kowalenko, MD;
Nathan R. Every, MD, MPH;
for the National Registry of Myocardial Infarction 2 and 3 Investigators
JAMA. 2001;286:1977-1984.
Context Although previous studies have suggested that normal and nonspecific initial electrocardiograms (ECGs) are associated with a favorable prognosis for patients with acute myocardial infarction (AMI), their independent predictive value for mortality has not been examined.
Objective To compare in-hospital mortality among patients with AMI who have normal or nonspecific initial ECGs with that of patients who have diagnostic ECGs.
Design, Setting, and Patients Multihospital observational study in which 391 208 patients with AMI met the study criteria between June 1994 and June 2000 and had ECGs that were normal (n = 30 759), nonspecific (n = 137 574), or diagnostic (n = 222 875; defined as ST-segment elevation or depression and/or left bundle-branch block). A logistic regression model was constructed using a propensity score for ECG findings and data on demographics, medical history, diagnostic procedures, and therapy to determine the independent prognostic value of a normal or nonspecific initial ECG.
Main Outcome Measures In-hospital mortality; composite outcome of in-hospital death and life-threatening adverse events.
Results In-hospital mortality rates were 5.7%, 8.7%, and 11.5% while the rates of the composite of mortality and life-threatening adverse events were 19.2%, 27.5%, and 34.9% for the normal, nonspecific, and diagnostic ECG groups, respectively. After adjusting for other predictor variables, the odds of mortality for the normal ECG group was 0.59 (95% confidence interval [CI], 0.56-0.63; P<.001) and for the nonspecific group was 0.70 (95% CI, 0.68-0.72; P<.001), compared with the diagnostic ECG group.
Conclusion In this large cohort of patients with AMI, patients presenting with normal or nonspecific ECGs did have lower in-hospital mortality rates than those of patients with diagnostic ECGs, yet the absolute rates were still unexpectedly high.
Author Affiliations: Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Mich (Drs Welch, Zalenski, Compton, Grzybowski, Thomas, and Kowalenko); Ovation Research Group (Mr Frederick); HealthStat Consulting Inc (Dr Malmgren); and Veterans Affairs Puget Sound Health System (Dr Every), Seattle, Wash. A list of National Registry of Myocardial Infarction 2 and 3 sites is available from Genetech, Inc, South San Francisco, Calif.
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