Clinical predictors of in-hospital prognosis in unstable angina: ECLA 3

Abstract

Objectives Because of recent changes in the treatment of unstable angina, we wanted to reassess the short-term prognostic value of clinical and echocardiographic variables. Methods This was an observational, prospective study that included 1038 nonselected consecutive patients admitted to coronary care units for unstable angina. Results Baseline characteristics were age 60.18 ± 16 years, history of prior myocardial infarction in 336 patients (32%), and a history of previous angina in 817 patients (78.7%). Angina during the 48 hours before admission was observed in 1004 patients (96.7%) and ST-segment changes on admission electrocardiogram occurred in 385 patients (37%). In-hospital treatment consisted of nitrates in 81.4% of patients, aspirin in 88.6%, β-blockers in 71%, intravenous heparin in 34.5%, subcutaneous heparin in 23%, and angioplasty or coronary artery bypass grafting in 25.1%. After admission, angina occurred in 443 patients (40.8%), refractory angina in 223 patients (21.5%), and death or myocardial infarction in 84 patients (8.1%). At admission, the independent predictors of myocardial infarction or death identified by multivariate logistic regression analysis were ST-segment depression (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.23 to 3.68, P =.006), prior angina (OR 2.23, 95% CI 0.98 to 5.05, P =.05), number of episodes of angina within the previous 48 hours (OR 1.63, 95% CI 0.98 to 2.70, P =.05), and history of smoking (OR 0.69, 95% CI 0.56 to 0.85, P =.004). Age greater than 65 years (OR 1.49, 95% CI1.09 to 2.03, P = 0.03) was significantly related to in-hospital death. The area under the receiver operating characteristic curve for application of this model was 0.59. Sensitivity was 80% with a specificity of only 33%. Refractory angina after admission showed a strong relation with an adverse short-term outcome. Conclusions With current therapy, clinical and electrocardiographic variables provide useful information about the short-term outcome of unstable angina. However, this model has low specificity to identify high-risk patients. Future studies about the incremental value of the new serum markers such as troponin T and C-reactive protein to assist in identification of high-risk patients are necessary. (Am Heart J 1999;137:322-31.)