Killip Class II-IV Research Articles

Blood lactate is a predictor of short-term mortality in patients with myocardial infarction complicated by heart failure but without cardiogenic shock

BackgroundMortality in patients with acute myocardial infarction (AMI) has improved substantially with modern therapy including percutaneous coronary interventions (PCI) but remains high in certain subgroups such as patients presenting with overt cardiogenic shock. However, the risk for AMI in patients presenting acutely with signs of heart failure but without cardiogenic shock is less well described. We aimed to identify risk factors for mortality in AMI patients with heart failure without overt cardiogenic shock.MethodsUsing data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), we identified patients with operator-registered heart failure (Killip class II-IV), and evaluated predictors of mortality based on clinical factors from review of patient records.ResultsA total of 1260 unique patients with acute myocardial infarction underwent PCI in 2014, of which 77 patients (7%) showed signs of heart failure (Killip II-IV) Overall 30-day mortality in patients with Killip class II-IV was 20% (N = 15). In patients classified Killip IV (1%), 30-day mortality was 50% (N = 6). In patients presenting with mild to moderate heart failure (Killlip class II-III), 30-day mortality was 14% (N = 9). In patients with Killip class II-III, lactate ≥2.5 mmol/L was associated with 30-day mortality, whereas systolic blood pressure < 90 mmHg, age, sex and BMI were not. In patients with lactate < 2.5 mmol/L 30-day mortality was 5% (N = 2) whereas mortality was 28% (N = 7) with lactate ≥2.5 mmol/L. This cut-off provided discriminative information on 30-day mortality (area under ROC curve 0.74).ConclusionsIn patients with AMI and signs of mild to moderate heart failure, lactate ≥2.5 mmol/L provides additional prognostic information. Interventions to reduce risk may be targeted to these patients.

Activities of daily living as an additional predictor of complications and outcomes in elderly patients with acute myocardial infarction.

BackgroundAge is an important determinant of outcome in acute myocardial infarction (AMI). However, in clinical settings, there is an occasional mismatch between chronological age and physical age. We evaluated whether activities of daily living (ADL), which reflect physical age, also predict complications and prognosis in elderly patients with AMI.DesignSingle-center, observational, and retrospective cohort study.MethodsPreserved ADL and low ADL were defined according to the scale for independence degree of daily living for the disabled elderly by the Japanese Ministry of Health, Labour, and Welfare. We examined 82 consecutive patients aged ≥75 years with AMI who underwent primary percutaneous coronary intervention. Patients were divided into preserved ADL (n=52; mean age, 81.8±4.8 years; male, 59.6%) and low ADL (n=30; mean age, 85.8±4.7 years; male, 40.0%) groups according to prehospital ADL.ResultsThe prevalence of Killip class II–IV and in-hospital mortality rate were significantly higher with low ADL compared to that with preserved ADL (23.1% vs 60.0%, P=0.0019; 5.8% vs 30.0%, P=0.0068, respectively). Multivariate analysis showed that ADL was an independent predictor of Killip class II–IV and 1-year mortality after adjusting for age, sex, and other possible confounders (odds ratio 5.11, 95% confidence interval [CI] 1.52–17.2, P=0.0083; hazard ratio 4.32, 95% CI 1.31–14.3, P=0.017, respectively).ConclusionPrehospital ADL is a significant predictor of heart failure complications and prognosis in elderly patients with AMI undergoing primary percutaneous coronary intervention, irrespective of age and sex.

Predictability of adverse clinical events following ST-elevation myocardial infarction by risk assessment tools

Background: Killip classes, TIMI and GRACE scores are simple validated clinical risk scores used in risk stratification in acute coronary syndrome including ST-elevation myocardial infarction (STEMI). Objectives: Our study aimed to determine the predictive ability of post-myocardial adverse events by commonly used clinical risk scores. Materials and Methods: Data were analysed from 120 male patients with acute STEMI, admitted to Teaching Hospital, Karapitiya. The risk scores were calculated during the acute phase. Patients were followed up for 365 days for the occurrence of clinically significant adverse cardiovascular events. Results: Adverse clinical events related to STEMI developed in 50(41.7%) patients during the hospital stay. Later, during the follow up of 365 days, 39 (32.5%) patients developed major complications. Killip class II-IV was significantly (p = 0.001) associated with adverse clinical events during the hospital stay, but not later. TIMI score was a significant predictor of the occurrence of the clinically significant STEMI related adverse events, while in the ward (p = 0.004, OR = 1.51) and during the first 30 days (p = 0.008, OR = 1.42), but not beyond this period. GRACE score was unable to predict the adverse cardiovascular events in this patient cohort. Negative predictive values for both TIMI and GRACE scores were close to 100 at each time interval. Conclusions: The development of major complications or adverse clinical events following STEMI was less common in the cohort. The TIMI score could predict the adverse events until 30 days, but not later. GRACE score was unable to predict adverse events. Killip class grading was strongly associated with the major complications occurred during the hospital stay.

Incidence, predictors and prognostic implications of bleeding complicating primary percutaneous coronary intervention

Data about bleeding complicating primary percutaneous coronary intervention (PCI) are more frequently obtained from randomized clinical trials on patients with acute coronary syndromes (ACS), but less frequently from surveys or registries on patients with ST-elevation myocardial infarction (STEMI). The aim of this study was to investigate the incidence, predictors and prognostic impact of in-hospital major bleeding in the population of unselected real-world patients with acute STEMI undergoing primary PCI. All consecutive patients presenting with STEMI who underwent primary PCI at a single large tertiary healthcare center between January 2005 and July 2009, were studied. Major bleeding was defined according to the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) study criteria. We examined the association between in-hospital major bleeding and death or major adverse cardiac events (MACE) in patients treated with PCI. The primary outcomes were in-hospital and 6-month mortality and MACE. Of the 770 STEMI patients treated with primary PCI, in-hospital major bleeding occurred in 32 (4.2%) patients. Independent pre-dictors of major bleeding were advanced age (≥ 65 years), female gender, baseline anemia and elevated white blood cell (WBC) count and signs of congestive heart failure at admission (Killip class II-IV). In-hospital and 6 month mortality and MACE, rates were more than 2.5-fold-higher in patients who developed major bleeding compared with those who did not. Major bleeding was predictor of 6-month MACE, independent of a few risk factors (previous MI, previous PCI, diabetes mellitus and hypertension); (OR = 3.02; 95% CI for OR 1.20-7.61; p = 0.019) but was not a true independent predictor of MACE and mortality in the fully adjusted models. Patients of advanced age, female gender, with baseline anemia and elevated WBC count and those with Killip class II-IV at presentation are at particularly high risk of bleeding after primary PCI. Bleeding is associated with adverse outcome and may be an important marker of patient frailty, but it is not a true independent predictor of mortality/MACE.

The Impacts of Living Alone in in-Hospital and One-Year Clinical Outcomes after Acute Myocardial Infarction in Korean Patients

Objective: The aim of this study is to evaluate the impact of living alone for in-hospital and one-year clinical outcome after acute myocardial infarction (AMI) in Korean patients. Methods: A total of 1,700 patients who admitted at the Chonnam National University Hospital were analyzed. We divided the patients into two groups by the existence of a spouse or family member that lived together with the patient at the first time of hospital visit due to AMI. The primary endpoint was composed of in-hospital death and cardiac death during one-year clinical follow-up. Secondary end point was other major adverse cardio-cerebral events (MACCE) including non-fatal MI, repeat revascularization, ischemic or hemorrhagic stroke during one-year clinical follow-up. Result: Living alone patient group had higher proportion of Killip class II-IV (34.3% vs. 26.6%, p=0.006) and higher value of high sensitivity C-reactive protein (2.2±4.0 vs. 1.5±3.4 ng/mL, p=0.019) than not living alone group. In-hospital death (8.9 % vs. 5.1%, p=0.010) and one-year cardiac death (7.7% vs. 4.6%, p=0.031) developed more in living alone groups. However, living alone was not an independent prognostic factor for in-hospital death (HR 1.51, 95% CI 0.91-2.52, p=0.113) and one-year cardiac death (HR 1.18, 95% CI 0.59-2.34, p=0.64) after multivariate analysis. Conclusion: Living alone was not an independent prognostic factor for in-hospital and one-year clinical outcome after AMI.

Invasive treatment strategy in elderly patients with non ST elevation acute coronary syndromes. A sensitivity analysis of a large monocentric retrospective study

Background: Consistent benefit of invasive strategy (IS) in the management of myocardial infarction (MI) in elderly patients is not yet reported. Objectives: In non ST elevation acute coronary syndromes (NSTEACS) admitted within 48h of symptom onset, we aimed to determine in-hospital and 30-days mortality, and proportion of patients alive at 31 days to 6 months (T1) and 31 days to 12 months follow-up (T2). Cumulative rate of composite outcome (CO) of death/nonfatal MI/unstable angina was also analysed at 30 days, 6 and 12 months. Methods: A retrospective review of 453 consecutive patients > 75 yrs discharged after NSTEACS at a single ICCU between 2006 and 2010 was conducted. IS (n=301) or conservative strategy (CS) (n=152) were chosen as per medical judgment. Multivariate regression models to test the association between strategy and outcomes were used and a sensitivity analysis performed. Variables introduced into the models were age, gender, admission creatinine clearance, ejection fraction, haemoglobin and Killip classes, admission heart rate, blood pressure and cardiac arrest, ST deviation, peak troponin level, time from admission to percutaneous coronary intervenion (PCI), albumin serum levels. Results: Inhospital, 8 (2.7%) and 14 (9.2%), at 30 days, 11 (3,7%) and 21 (13,8%), at T1 28 (9,3%) and 44 (29,0%), and at T2 40 (13,3%) and 57 (37.5%), patients died in the IS and CS group respectively. At 30 days 25 (8,3%) and 24 (15,8%), at T1 52 (17,3%) and 56 (36,8%), and at T2 74 (24,6%) and 64 (42.1%), patients achieved the cumulative CO in the IS and CS group respectively. IS sizeably decreased adjusted in-hospital (OR 0.37, 95% CI 0.13-1.04, p=0.0603), 30-days (OR 0.28, 95% CI 0.12-0.67, p=0.004), T1 (T1 OR 0.33, 95% CI 0.16-0.67, p=0.0025) and T2 mortality (T2 OR 0.34, 95% CI 0.20-0.58, p=0.0001). IS correspondingly lowered cumulative rate of CO at 30 days (OR 0.55, 95% CI 0.28-1.07, p = 0.077), 6 months (OR 0.52, 95% CI 0.34-0.81, p = 0.003) and 12 months (OR 0.68, 95% CI 0.46-0.98, p = 0.0041). Further independent predictors of prognosis were also hemodynamic status (Killip class II-IV), or cardiac arrest at admission. Conclusions: IS was independently associated with a three-fold lower mortality and twofold lower CO in this high risk population at either brief, mid or long-term.

A low pulse pressure predicts mortality in subjects with heart failure after an acute myocardial infarction: a post-hoc analysis of the CAPRICORN study

In patients with cardiovascular disease, a high pulse pressure is related to an increased risk of cardiovascular events but in patients with advanced heart failure, a low pulse pressure is predictive of adverse (cardiovascular) events. We studied the prognostic importance of pulse pressure in a group of post-myocardial infarction patients, with and without signs and symptoms of heart failure. Subjects had been randomised in the CAPRICORN clinical trial, and followed up for a mean of 1.3 years. Blood pressure was measured in 1,955 patients with a left ventricular ejection fraction ≤40%, between 3 and 21 days post myocardial infarction. Cox proportional survival models were reproduced for those with Killip Class I (n = 1342) versus classes II/III/IV heart failure (n = 613). Overall mean (SD) age was 63 (12) years, mean (SD) left ventricular ejection fraction 33(6)%, mean (SD) baseline blood pressure was 121 (17)/74 (10) mmHg and most (73%) were male. In patients with Killip Class 1, pulse pressure was not predictive for any outcome. However, in patients with Killip Class II-IV, a low pulse pressure independently predicted all cause mortality (HR 0.83 per 10 mmHg, CI 0.71-0.98, p = 0.025), cardiovascular mortality (HR 0.83 per 10 mmHg, CI 0.70-0.98, p = 0.025) and sudden death (HR 0.77 per 10 mmHg, CI 0.60-1.00, p = 0.047). A lower pulse pressure did not predict hospitalisation for worsening heart failure. A low pulse pressure is an independent predictor of mortality in subjects with depressed left ventricular ejection fraction after a recent myocardial infarction and evidence of Killip Class II-IV heart failure.

Effect of Narcotic Treatment on Outcomes of Acute Coronary Syndromes

Current guidelines have recommended intravenous narcotics (IVNs) for patients with ST-segment elevation acute coronary syndromes (STEACS) and patients with non-STEACS (NSTEACS), although the safety of IVNs has been challenged. We performed a retrospective analysis of the 30-day outcomes stratified by IVN use among patients enrolled in a national survey, using logistic regression and propensity score analysis. Of the 765 patients with STEACS and 993 patients with NSTEACS, 261 (34.1%) and 97 (9.8%) had received IVNs, respectively. The patients with STEACS who received IVNs were more likely to undergo reperfusion (79.7% vs 55.2%, p <0.0001), received it more rapidly (median 59 minutes vs 70 minutes, p = 0.02), and were more likely to undergo coronary angiography and revascularization. No difference was found in hemodynamic status. The patients with NSTEACS who received IVNs were more likely to present with Killip class II-IV (39.2% vs 10.0%, p <0.001) and to have left ventricular systolic dysfunction (39.0% vs 17.0%, p <0.001). No difference was found in the use of invasive procedures. Using propensity score analysis, of 249 matched STEACS pairs, the rate of 30-day death was lower in the group that had received IVNs (2.4% vs 6.2%, p = 0.04), and this trend persisted after logistic regression analysis (odds ratio 0.40, 95% confidence interval 0.14 to 1.14, p = 0.09). Using propensity score analysis, of 95 matched NSTEACS pairs, no difference was found in the 30-day death rate (2.2% for patients receiving IVNs vs 6.3%, p = 0.16), even after logistic regression analysis (odds ratio 0.56, 95% confidence interval 0.14 to 2.33, p = 0.43). In conclusion, IVNs were commonly used in different scenarios-patients with STEACS were more likely to receive IVNs in the context of prompt reperfusion, and patients with NSTEACS were more likely to receive IVNs in the context of heart failure. In both scenarios, IVN use did not adversely affect the outcomes.

Low Serum Albumin Levels and In-Hospital Adverse Outcomes in Acute Coronary Syndrome

Epidemiological studies have demonstrated an association between low serum albumin levels and coronary heart disease and mortality. Nevertheless, the impact of a low serum albumin level during acute coronary syndrome has not yet been established. The aim of the present study was to investigate whether low serum albumin levels are associated with adverse outcomes in acute coronary syndrome. We enrolled 82 consecutive patients with acute coronary syndrome from whom venous blood for serum albumin measurement was drawn immediately upon hospital admission. Thirty-five patients had a low albumin level (hypoalbuminemia) and 47 had a normal albumin level (normoalbuminemia). In-hospital adverse outcomes (death, acute heart failure, cardiogenic shock, and reinfarction) were recorded during hospitalization in the intensive coronary care unit. The results of our study showed that the incidence of in-hospital adverse outcomes was 43%, with death occurring in 8 patients (10%). In-hospital adverse outcomes occurred more frequently in patients presenting with hypoalbuminemia, whereas mortality did not differ significantly. Univariate analysis showed that hypoalbuminemia was associated with a 2.8-fold greater risk of developing adverse outcomes. This risk was greater in the subgroup of NSTEACS (5.4-fold increased risk), but not in those with STEMI. Adjustment with other covariates revealed that hypoalbuminemia did not predict independently in-hospital adverse outcomes. It interacted with other predictors, especially Killip class II-IV, which was consistently an independent predictor of in-hospital adverse outcomes.

Abstract 2656: Copeptin Predicts Cardiovascular Death in STEMI Independent of Clinical Factors and NT-proBNP

Background : Elevated levels of copeptin, the c-terminal portion of provasopressin, add significantly to natriuretic peptides for mortality prediction in heart failure. We hypothesized that elevated levels would predict mortality in ST-elevation myocardial infarction (STEMI). Methods : Circulating copeptin levels were measured at baseline in a case-cohort of 535 STEMI patients undergoing fibrinolysis in CLARITY-TIMI 28. Patients were stratified into quartiles by baseline copeptin. Multivariable logistic regression was used to examine the association between copeptin and 30-d cardiovascular (CV) mortality independent of clinical factors and NT-proBNP. Results : The median level of copeptin was 615 pg/ml (IQR 333–728 pg/ml). Baseline levels of copeptin tended to be higher in patients who were older, had a prior MI, were treated sooner after sx onset, and were in Killip class II-IV. For each 1-SD increase in log-transformed copeptin, the OR for CV death was 1.45 (p=0.01). After adjusting for differences in baseline characteristics patients in the highest copeptin quartile were at a significantly higher risk of CV death compared with patients in quartiles 1–3 (OR 1.99 [1.05–3.78]). Copeptin was not significantly correlated with NT-proBNP (r=0.09). In a multivariable model, copeptin and NT-proBNP were each significant independent predictors of CV death (Figure ); the c-statistic went from 0.75 to 0.81 with their addition to a model containing clinical risk factors. Conclusion : In a multimarker model, circulating levels of copeptin and NT-proBNP at presentation were powerful and complementary predictors of CV death beyond traditional risk factors in patients with STEMI.

Modalities of treatment and 30-day outcomes of unselected patients older than 75 years with acute ST-elevation myocardial infarction: data from the BLITZ study

The optimal treatment strategy for elderly patients presenting with ST-elevation myocardial infarction is still controversial and few investigations have studied this high-risk population in a community setting. We analyzed data from the BLITZ survey on patients with any acute myocardial infarction admitted to the Italian Coronary Care Unit (CCU) network, in order to assess current treatment strategies among unselected patients older than 75 years presenting with ST-elevation myocardial infarction. We also evaluated the 30-day rates of major adverse cardiovascular events (death/re-myocardial infarction/stroke) relative to different treatment strategies. The registry included 1959 patients, of whom 529 (27%) were over 75 years old. According to the ECG on admission, 296 of these patients (56%) were classified as having ST-elevation myocardial infarction: 26 (8.8%) underwent primary percutaneous coronary intervention, 101 (34.1%) were treated with systemic thrombolysis, and the remaining 169 (57.1%) did not receive any early reperfusion therapy. At 30-day follow-up, the cumulative rate of major adverse cardiovascular events was not significantly different among the three treatment modality groups (31.4, 27.7, and 23.1% among no reperfusion, thrombolysis and primary percutaneous coronary intervention groups, respectively; P = 0.59). On multivariable analysis, age [odds ratio (OR) x 5-year increment 1.5; 95% confidence interval (CI) 1.2-2.0; P = 0.007], Killip class II-IV at admission (OR 3.7; 95% CI 2.1-6.3; P < 0.0001), and coronary multivessel disease (OR 2.4; 95% CI 1.1-5.3; P = 0.03) were the only independent predictors of major adverse cardiovascular events. In a nationwide clinical practice, the vast majority of patients older than 75 years presenting with ST-elevation myocardial infarction does not receive any early reperfusion treatment and presents a significant incidence of major clinical events at 30 days.

The risk of cardiovascular death following the first acute ischaemic syndrome: experience in Kaunas between 1997 and 2001

The aim of our study was twofold: initially to investigate the effects of the informative value of the variables of the acute period on the risk of cardiovascular death during the long-term period following the first acute coronary syndrome, and then to determine the long-term survival rate in different risk groups.Methods — The prospective five-year observational study included 732 patients with acute coronary syndrome who had survived the hospital period. Employing multivariable Cox’s proportional-hazard analysis, the most informative variables were selected, the risk score index was calculated, the risk groups for the prediction of cardiovascular death were identified, long-term survival (4.5 ± 2.1 years) in different risk groups was determined and internal validation of the model was performed.Results — During the observational period, 84 patients (11.5%) died due to cardiovascular causes. Cox proportional-hazard models demonstrated that six variables had significant influence on long-term survival during the five-year period after an acute coronary syndrome. These variables were: age [1-5 points], the presence of pathologic Q wave in > 2 ECG leads [2 points], Killip class II-IV [24 points], left ventricular ejection fraction < 35% [2-4 points], proximal stenosis of coronary arteries [2-4 points], absence of myocardial revascularization in the acute period [2 points].Three strata for risk of cardiovascular death were identified [0-5 points - 14.1% patients, 6-10 points - 62.6%, > 10 points - 23.3%].The probability of survival within the period of five years was found to be favourable for the majority of patients in the low- and medium-risk groups, while the number of such patients in the high-risk group was significantly lower [97.0% vs. 89.0% vs. 73.0%, P< 0.0000].The difference in the survival probability was negligible in developmental and validation sets.Conclusion — The risk score derived from clinical variables of first acute coronary syndromes permits a reliable determination of risk for cardiovascular death as well as the prediction of long-term survival in different risk groups.

Relationship between circulating endothelial cells and the predicted risk of cardiovascular events in acute coronary syndromes

The quantification of circulating endothelial cells (CECs) in whole blood is a novel marker of direct endothelial injury and shows promise as a potential biomarker of cardiovascular (CV) risk. The inter-relationship(s) between CECs and predicted CV risk has not been explored in large cohort of 'high-risk' patients. We hypothesized that there would be a significant relationship between increasing CEC counts and predicted CV risk in a broad spectrum of patients presenting with acute coronary syndrome (ACS). We studied 197 patients (aged 40-80 years) admitted with a confirmed diagnosis of unstable angina (UA), non-ST-elevation myocardial infarction (MI, NSTEMI), or ST-elevation MI (STEMI). CEC counts were performed on venous whole blood using the immunobead technique. Four well-validated ACS risk scores [(PURSUIT and TIMI for NSTEMI/UA) TIMI (STEMI) and GRACE (all ACS)] were calculated from the initial clinical history and electrocardiogram, as well as from values of laboratory parameters collected within 12 h of admission. We included a healthy control (HC) group of 50 matched patients in order to quantify the accuracy of CEC counts for the diagnosis of ACS and to compare disease vs. HC counts. CEC counts were significantly higher in the disease group when compared with the HC group. CEC counts significantly increased with increasing severity of disease (that is, UA vs. NSTEMI vs. STEMI; P = 0.002). CEC counts were higher among patients with clinical evidence of heart failure (Killip Class II-IV) when compared with those without (Killip Class I) on admission (P < 0.0001). There was a significant correlation between CEC counts and predicted CV risk for each of the four ACS risk scoring schemes (all P < 0.05). The area under the receiver-operating characteristic (ROC) curve (AUC) for the entire ACS cohort was 0.82 (95% CI: 0.76-0.88; P < 0.0001). A CEC count of >or=7/mL provided a positive predictive value of 90.6% (95% CI: 85.6-95.7%) and a negative predictive value of 53.5% (41.9-65.1%) for the diagnosis of MI (NSTEMI/STEMI) in the presence of an appropriate clinical presentation. There is a significant and positive correlation between increasing CECs and increasing CV risk in ACS. The diagnostic accuracy of CECs in this setting is only 'moderate'. Whilst it is good at confirming the presence of MI, a CEC value of <7.0/mL is less reliable at confidently excluding patients without disease.

Clinical Characteristics of Acute Myocardial Infarction Died during Hospitalization

Background:Recently, the incidence of acute myocardial infarction (AMI) rapidly increased with prolongation of life spans, improvements of food and life styles in Korea. The mortality rate of AMI is higher than other disease. The purpose of this study is to evaluate which factors can affect the early outcome of AMI in Korean. Methods:A retrospective clinical study was done on 555 consecutive patients{Male:Female=387 (69.7%): 168 (30.3%), mean age 61.3 years} with AMI who had been admitted to Dong-San Medical Center from January 1990 to May 1997. The subjects were devided into two groups. Group I was dead patients during the in-hospital period (85 patients, 15.3%), and Group II was living patients (470 patients, 84.7%) wen they discharged from hospital. We compared clinical and laboratory results in both groups and analysed the cause of death according to the time of death during hospitalization. Results:The results were as follows;1) The mean age and female percentage of Group I (65.4 years, 43%) were higher than Group II (60.5 years, 28%). The mean of systolic/diastolic blood pressure and percentage of smoker of Group I (108/65 mmHg, 48%) were lower than Group II (125/76 mmHg, 65%), significantly. 2) The degree of Killip classification was higher in Group I (class 1:29.4%, II:18.8%, III:21.2%, IV:30.6%) than in Group II patients (class 1:73.4%, II:13.6%, III: 8.7%, IV:4.3%), significantly. 3) 47 patients were died first day of hospitalization and the most common cause of death was cardiogenic shock (27 patients, 31%). The most common cause of death within 1 week was cardiogenic shock, afterthen congestive heart failure. 4) The most common cause of death in Killip class I patients was ventricular tachycardia or ventricular fibrillation and in Killip class II-IV patients was cardiogenic shock. Conclusion:The risk of in-hospital death was higher in elderly, female sex, and patients with higher Killip classification. Cardiogenic shock was most common cause of death within 1 week, and was congestive heart failure after 1 week. (Korean Circulation J 1998; 28(9):1518-1526)