Acute Coronary Syndrome in Phrae Hospital

Transcription

1 Acute Coronary Syndrome in Phrae Hospital Cardiovascular Unit, Department of Medicine, Phrae hospital, Phrae Thailand. Objective: To study the epidemiology, management and outcome of patients with acute coronary syndrome [ACS] who were admitted to Phrae hospital. Methods: The data was collected from a prospective registry of patients diagnosed with ACS who were admitted to Phrae hospital between 1 August 24 and 31 July 25. Results: There were 28 cases of ACS admitted to Phrae hospital during the study period. Of these patients, 48.1% had ST-segment elevation acute coronary syndrome [], 51.9% had no ST-segment elevation acute coronary syndrome [No], 11.5% had non ST-segment elevation myocardial infarction, and 4.4% had unstable angina. Over half of these patients [57.7%] were > 65 years old, 45.2% were female and 87% had at least one risk factor. Thrombolytic therapy was used in 6% of cases; 23% received it within 3 minutes of admission, and 35% within 3 hours of the onset of symptoms. In-hospital mortality was 9.6% overall and 15.% for which was significantly higher than 4.6% for No, p=.17. Factors associated with increased mortality were cardiogenic shock, ventricular arrhythmia, complete heart block and an initial systolic blood pressure < 1 mmhg. There was a high rate of congestive heart failure [CHF] in both diagnostic groups. Factors associated with CHF were age > 75 years, female and time delay from the onset of symptoms to admission. Conclusions: The results of this study provide additional data concerning ACS in a rural population. There was a high rate of both in-hospital mortality and complications. These findings suggest that there would be benefits from developing improved guidelines for ACS management, management of acute complications and referral systems of patients with ACS admitted in Phrae hospital. Key words: Acute coronary syndrome, ST-elevated acute coronary syndrome, No ST-elevated acute coronary syndrome Thai heart J 26; 19 : E-Journal : Introduction Acute coronary syndrome [ACS] is the most common cause of death in most western industrialized countries 1,2. There have been several studies published concerning ACS in the Thai population 3,4 and Thai acute coronary syndrome data [Thai ACS registry] has been collected by The Heart Association of Thailand under The Royal Patronage for some years already 5. Guidelines describing up to date management of the acute coronary syndrome are readily available 6,7. However most of the data analysis has been based on urban populations in tertiary medical care facilities or teaching hospitals. There is only limited data on how patients with ACS are actually managed in rural areas or primary medical care hospitals where there is a restricted range of available medications and limited access to new treatment strategies. The purpose of this article is to study the epidemiology, management and outcome of patients with ACS who were admitted in Phrae hospital. Methods Study Patients The data were collected from a prospective registry of patients who were admitted to Phrae hospital between 1 August 24 and 31 July 25 with a diagnosis of acute myocardial infarction [both STsegment elevation and Non-ST-segment elevation myocardial infarction] or unstable angina Operational Definition ST elevated acute coronary syndromes []: including ST- segment elevation myocardial infarction (STEMI) or new LBBB THAI HEART JOURNAL Vol. 19 No.3 July 26

2 Acute coronary syndrome in Phrae hospital 97 No ST elevated acute coronary syndromes [No]: including non ST- segment elevation myocardial infarction (NSTEMI) and unstable angina (UA). The diagnosis of AMI was defined using the WHO criteria: presence of two or more of the following 3 criteria 1. A clinical history of ischemic-type chest discomfort 2. Changes on serially obtained electrocardiographic tracings. 3. A rise of CK-MB > 25 ng/ml or troponin T >.1 ng/ml Classification of STEMI vs. NSTEMI 8 the patient should manifest a more rapid typical rise and fall (CK-MB) of biochemical makers of myocardial necrosis and 1. ST-segment elevation myocardial infarction[stemi] :ST-segment elevation: New or presumed new LBBB or ST-segment elevation at the J point in 2 or more contiguous leads with the cutoff points greater than or equal to.2 mv in leads V1, V2, or V3, or greater than or equal to.1 mv in other leads. 2. Non-ST-segment elevation myocardial infarction [NSTEMI]: Either of the following (in the absence of ST elevation): ST-segment depression or T- wave abnormalities with ischemic symptoms in the presence or absence of chest discomfort. Unstable angina [UA] 8 defined as angina pectoris (or equivalent type of ischemic discomfort) with any 1 of the 3 following features: Angina occurring at rest and prolonged, usually greater than 2 minutes New-onset angina of at least CCS classification III severity Recent acceleration of angina reflected by an increase in severity of at least 1 CCS class to at least CCS class III Diabetes mellitus (DM): history of DM, regardless of duration of disease, need for antidiabetic agents, or fasting blood sugar > 126 mg/dl Hypertension (HT): HT as documented by 1. History of HT diagnosed and treated with medication, diet, and/or exercise 2. BP>14mmHg systolic or >9 mmhg diastolic on at least 2 occasions 3. Current use of antihypertensive pharmacological therapy Dyslipidemia: history of dyslipidemia diagnosed and/or treated by a physician. National Cholesterol Education Program criteria include documentation of the following 1. cholesterol >2 mg/dl or 2. Low-density lipoprotein (LDL) > 13 mg/dl or 3. High-density lipoprotein (HDL) < 4 mg/dl Smoking: smoking cigarettes within 1 year of this admission. Statistical Analysis Continuous variables were expressed as mean + SD or median when appropriate, discrete variables are expressed as percentages. Differences in the distribution of selected characteristics between patient groups were examined using the Chi-square test for categorical variables. Differences in continuous variables between study groups were analyzed using either analysis of variance or t tests. A p-value less than.5 was considered statistically significant. All statistical data were analyzed by SPSS program for windows version Results Of the 28 patients with acute coronary syndromes enrolled from 1 August 24 to 31 July 25; 1 [48%] presented with and 18 [51.9%] presented with No. The patients baseline characteristics and risk factors are listed in Table 1. The median age was 67 years [interquartile range of 21 to 87 years] and 94 [45.2%] were women. Most patients had at least one risk factor, 128 [64%] had hypertension and 77 [37%] had diabetes. There were major differences in smoking rates, which were much more frequent in patients admitted for STE- ACS (33%) than for No (15.7%). A history of IHD was more frequent among patients with No than. More than half of the patients were > 65 years old. Patients admitted for were significantly younger than the NoSTE- ACS. There was a trend toward increasing frequency of unstable angina and decreasing frequency of the presentation as STEMI with advanced age [Table2 & Figure 1]. Sixty-nine of the patients with STEMI had anterior wall infarction and most patients of NoSTE- ACS had unstable angina [Table 3] The pharmacologic treatment of patients with ACS is listed in Table 4. A thrombolytic agent was used in 6% of the patients with. Lowmolecular-weight-heparin was used in 9.7% of THAI HEART JOURNAL Vol. 19 No.3 July 26

3 98 Table 1. Patients baseline characteristics [n=28] [n=1] No [n=18] Median age [range,yrs] Age [yrs] < >75 67 [21-87] 8 [3.9%] 34 [16.3%] 46 [22.1%] 83 [39.9%] 37 [17.8%] 64.5 [21-85] 5 [5.%] 26 [26.%] 19 [19.%] 41 [41.%] 9 [9.%] 71 [36-87] 3 [2.8%] 8 [7.4%] 27 [25.%] 42 [38.9%] 28 [25.9%] <.1* <.1* Women Risk factor -Diabetes -Hypertension -Dyslipidemia - Smoking** Number of risk factor*** 1 2 >3 Prior diseases -History of IHD -History of Stroke Time to admission# [mean+sd; min] 94[45.2%] 77 [37%] 128 [61.5%] 66 [31.7%] 5 [24.%] 27[13.%] 79[38.%] 7[33.6%] 32[15.4%] 7 [33.7%] 1 [.5%] [47.%] 34 [34.%] 63 [63.%] 34 [34.%] 33 [33.%] 9[9.%] 37[37.%] 39[39.%] 15[15.%] 26 [26.%] 1 [1.%] [43.5%] 43 [39.8%] 65 [6.2%] 32 [29.6%] 17 [15.7%] 18[16.7%] 42[38.9%] 31[28.7%] 17[15.7%] 45 [41.7%] * * *Statistically significant, ** Current smoker or history of smoking <1 year, ***Risk factors: diabetes, hypertension, dyslipidemia and smoking, # From symptom onset to hospital arrival. UA = Unstable angina UA NSTEMI STMEI Figure 1. Diagnosis according to age patients with No and aspirin was used in 97% of patients. Nearly 6% of patients received a B-blocker and a statin. Nearly 7% of patients received an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB). Mean door to needle time for patients with who received thrombolytic therapy was 84 minutes [median 7 minutes; range 5-3 min] and thrombolytic therapy was initiated within 3 minutes in 23% of cases. [Figure 2]. Thrombolytic therapy was initiated within 3 hours after symptom in 35% of the cases [Figure 3]. Hospital mortality was 9.6% overall and 15% for patients with which was significantly higher than 4.6% for patients with No. The other outcomes are listed in Table 5. Patients with suffered from more complications than patients with No except for congestive heart failure which was similar at 41% in both groups. The mean length of hospital stay was 6.5 days for patients with which was significantly higher than 5.4 days for patients with No. Approximately 85% of all patients with ACS improved and were discharged, and 3.4% were referred to a tertiary care hospital. THAI HEART JOURNAL Vol. 19 No.3 July 26

4 Acute coronary syndrome in Phrae hospital 99 Table 2. Diagnosis according to age Age [years] STEMI NSTEMI Unstable angina < >75 5 [5.%] 26 [26.%] 19 [19.%] 41 [41.%] 9 [9.%] 2[8.3%] 8[33.3%] 5[2.8%] 9[37.5%] 3[3.6%] 6[7.2%] 19[22.6%] 37[44.%] 19[22.6%] Table 3. Diagnosis according to gender 28 Figure 2. Door to Needle [Thrombolytic] time in STEMI Diagnosis Male Female I. STEMI -Anterior wall -Inferior wall -Other wali II. NSTEMI III.Unstable angina 53[46.5%] [7.9%] 52 [45.6%] 47 [5%] [16.%] 32 [34.%] 1 [48.1%] [4.4%] Figure 3. Symptom to Thrombolytic time Table 4. Pharmacologic treatment* during hospital stay and at discharge Streptokinase** Enoxaparin** No streptokinase and no enoxaparin Aspirin B-blockers ACEI or ARB Statins Nitrates Calcium antagonists IV. Inotropic drug** [No;%] 6 [6.%] 38 [38.%] 2 [2.%] 97 [97.%] 57 [57.%] 73 [73.%] 59 [59.%] 84 [84.%] 3 [3.%] 18 [18.%] No [No;%] 98 [9.7%] 1 [9.3%] 15 [97.2%] 64 [59.3%] 71 [65.7%] 6 [55.6%] 96 [88.9%] 3 [2.8%] 6 [5.6%] [No;%] 6 [28.8%] 136 [65.4%] 12 [5.8%] 22 [97.1%] 121 [58.2%] 144 [69.2%] 119 [57.2%] 18 [86.5%] 6 [2.9%] *Some patients received > 1 treatment. ** Statistically significant, P <.5 ACEI= angiotensin-converting enzyme inhibitor, ARB= Angiotensin II receptor blocker The fatal cases characteristics, risk factors and associated complication are listed in Table 6. Most fatal cases had and had a significantly higher number of life threatening complications than nonfatal cases; cardiogenic shock, VT/VF, complete heart block or low initial systolic blood pressure. More than 4% of both fatal and non-fatal cases had congestive heart failure. Mean door to needle time was 14 minutes in fatal cases which was longer than 81 minutes in non-fatal cases but this difference was not statistically significant. The heart failure cases characteristics, risk factors and associated complication are listed in Table 7. The proportion of women and age > 75 years was significantly higher for patients with CHF compared to patients without CHF. The mean delay between symptom onset and admission was significantly longer in patients with CHF compared with patients without CHF. Patients with CHF had a longer hospital stay than patients without CHF. Patients with who received delayed thrombolytic therapy >6 minutes after admission had higher rate of CHF than early thrombolytic <6 minutes [Odds ratio 4.22, 95% CI , P value.16]. The golden period for patients with who received thrombolytic therapy is demonstrated in Table 8 and 9. THAI HEART JOURNAL Vol. 19 No.3 July 26

5 1 Table 5. Hospital outcomes Outcome [n=28] [n=1] No [n=18] Death Congestive heart failure Cardiogenic shock VT/VF Complete heart block Major bleeding** Hospital stay [mean+sd;day] Improved & survived until discharge Not improved & rejected treatment Referred to a tertiary care hospital Bad outcome*** 2 [9.6%] 85 [4.9%] 2 [9.6%] 9 [4.3%] 2 [1.%] [85.1%] 4 [1.9%] 7 [3.4%] 15 [15.%] 41 [41.%] 18 [18.%] 17 [17.%] 9 [9.%] 2 [2.%] [75.%] 4 [4.%] 6 [6.%] 19 [19.%] 5 [4.6%] 44 [4.7%] 6 [5.6%] 3 [2.8%] [94.4%] 1 [.9%] 5 [4.6%].17*.97.8*.1*.1*.23.47* <.1* * VT/VF = ventricular tachycardia/ventricular fibrillation *significant difference **Major bleeding: intracerebral hemorrhage and Gastrointestinal bleeding ***Bad outcome= Death+ Not improved & rejected treatment Table 6. Characteristics of fatal outcomes Factor [n=28] Fatal [n=2] Non-fatal [n=188] Age >75 yr Male: Female Risk factors -Diabetes -Hypertension -Dyslipidemia - Smoking Number of risk factor 1 2 >3 37[17.8%] 114[54.8%]:94[45.2%] 77 [37%] 128 [61.5%] 66 [31.7%] 5 [24.%] 27 [13.%] 79 [38.%] 7 [33.6%] 32 [15.4%] 6 [3%] 11[55%]:9[45%] 7 [35%] 12 [6%] 4 [2%] 7 [35%] 3 [15%] 7 [35%] 8 [4%] 2 [1%] 31[16.5%] 13 [54.8%]:85[45.2%] 7 [37.2%] 116 [61.7%] 62 [33.%] 43 [22.9%] 24 [12.8%] 72 [38.3%] 62 [33.%] 3 [15.9%] Congestive heart failure Cardiogenic shock VT/VF Complete heart block Initial SBP<1 mmhg Time to admission# Door to needle time#,** Hospital stay [mean+sd;day] 85 [4.9%] 2 [9.6%] 9 [4.3%] 39 [18.8%] 1 [48.1%] [45%] 11[55%] 13[65%] 5 [25%] 9 [45%] 15 [75%] [4.4%] 13 [6.9%] 7 [3.7%] 4 [2.13%] 3 [16.%] 85 [45.2%] <.1* <.1* <.1*.4*.17* *Statistical significant, ** Only patients with thrombolytic, # mean+sd; minute THAI HEART JOURNAL Vol. 19 No.3 July 26

6 Acute coronary syndrome in Phrae hospital 11 Table 7. Characteristics of congestive heart failure outcome[chf] Factor [n=28] CHF [n=85] No CHF[n=123] Age >75 yr Male: Female Risk factors -Diabetes -Hypertension -Dyslipidemia - Smoking Number of risk factor 1 2 >3 37[17.8%] 114[54.8%]:94[45.2%] 77 [37%] 128 [61.5%] 66 [31.7%] 5 [24.%] 27 [13.%] 79 [38.%] 7 [33.6%] 32 [15.4%] 23[27.1%] 39[45.9%]:46[54.1%] 37[43.5%] 48[56.5%] 22[25.9%] 18[21.2%] 16[18.8%] 27[31.8%] 3[35.3%] 12[14.1%] 314[11.4%] 75[61.%]:48[39.%] 4[32.5%] 8[65.%] 44[35.8%] 32[26.%] 11[8.9%] 52[42.3%] 4[32.5%] 2[16.3%].5*.34* Cardiogenic shock VT/VF Complete heart block Initial SBP<1 mmhg Time to admission# Door to needle time#,** 2 [9.6%] 9 [4.3%] 39 [18.8%] 1 [48.1%] [12.9%] 9[1.6%] 3[3.5%] 21[24.7%] 41[48.2%] [1.6%] 11[8.9%] 6[4.9%] 18[14.6%] 59[47.8%] *.669 Hospital stay [mean+sd;day] <.1* *Statistically significant, # mean+sd; minute,** Only patients with thrombolytic treatment Table 8. Golden period in patients with thrombolytic therapy who had a fatal outcome Factor [n=6] Fatal [n=1] Non-fatal [n=5] Door to Needle time[minutes] < >9 Symptom to thrombolytic time [hours] < > [23.3%] 17 [28.3%] 9 [15.%] 2 [33.3%] 21 [35.%] 26 [43.3%] 12 [2.%] 1 [1.7%] 1 [1.%] 3 [3.%] 2 [2.%] 4 [4.%] 3 [3.%] 4 [4.%] 2 [2.%] 1 [1.%] 13 [26.%] 14 [28.%] 7 [14.%] 16 [32.%] 18 [36.%] 22 [44.%] 1 [2%] *Statistically significant, ** Current smoker or history of smoking <1 year, ***Risk factors: diabetes, hypertension, dyslipidemia and smoking, # From symptom onset to hospital arrival. UA = Unstable angina THAI HEART JOURNAL Vol. 19 No.3 July 26

7 12 Table 9. Golden period in patients with thrombolytic therapy who developed CHF Factor [n=6] CHF [n=23] No CHF [n=37] Door to Needle time[minutes] < >9 Symptom to thrombolytic time [hours] < > [23.3%] 17 [28.3%] 9 [15.%] 2 [33.3%] 21 [35.%] 26 [43.3%] 12 [2.%] 1 [1.7%] 4 [17.4%] 3 [13.%] 6 [26.1%] 1 [43.5%] 7 [3.4%] 11 [47.8%] 5 [21.8%] 1 [27.%] 14 [37.8%] 3 [8.2%] 1 [27.%] 14 [37.8%] 15 [4.5%] 7 [19.%] 1 [2.7%].49*.339 *Statistically significant, ** Current smoker or history of smoking <1 year, ***Risk factors: diabetes, hypertension, dyslipidemia and smoking, # From symptom onset to hospital arrival. UA = Unstable angina Discussion The management of ACS has been well defined by clinical trials and summarized in guidelines 6,7. However, real life patient populations sometimes differ markedly from those in clinical trials or guidelines. Geographic variations and different types of hospital provide an important opportunity to compare the use of different therapies. 9 Our data demonstrate the information gained about acute coronary syndromes in a rural population who received treatment in a primary care hospital with one cardiologist and five internists, no fibrin-specific thrombolytic agents, no invasive strategies for revascularization, no intra-aortic balloon pump and only a two bed coronary care unit. Baseline characteristics and risk factors of the patients in our study were comparable with other studies. Approximately half of the patients were > 65 years, but there was high proportion of women; nearly 45%. There was a trend towards increasing frequency of No and decreasing frequency of the presentation as STE- ACS with advanced age which is compatible with the GRACE registry and the Thai ACS registry. The lowest age in STEMI was a 21 year old who had a history of using amphetamines. The goal for patients with STEMI should be to achieve a door to needle time within 3 minutes and fibrinolysis is generally preferred in the cases of early presentation within 3 hours of symptom onset where there is delayed access to invasive strategies 7. In our study, streptokinase was the only choice of thrombolytic agent and was used in sixty percent of patients with STE- ACS. Eighty-two patients with arrived within 12 hours of symptom onset, 24 [29%] of these did not receive thrombolytic therapy. Moreover, door to needle time < 3 minutes occurred in only 23% of the cases and only 35% of the cases received thrombolysis within 3 hours of symptom onset. Our study revealed high in-hospital mortality, heart failure and cardiogenic shock which is in line with the Thai ACS registry which found higher levels than the GRACE registry. This may reflect less than ideal hospital management. Abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, and psychosocial factors were associated with more than 9% of the risk of an acute myocardial infarction which was studied in a large global case-control study 1. These results are consistent across all geographic regions and ethnic groups of the world, men and women, young and old. Eighty-seven percent of population in our study had at least one risk factor and there was a higher proportion of diabetes than in the GRACE registry. The association of lower hospital mortality with better use of selected medical treatments to improve survival in ACS have been clearly defined in clinical trials and guidelines 6,7,9. In our study ASA, B-blockers, ACEIs/ARBs and statins were used in 97%, 57%, 73% and 59% of patients respectively. This was higher than the study of Ratchaburi hospital 4 which had higher hospital mortality than our study. Except for B-blockers, other proven treatments used in our study were used more THAI HEART JOURNAL Vol. 19 No.3 July 26

8 Acute coronary syndrome in Phrae hospital 13 frequently than the GRACE registry however, this was not associated with a lower hospital mortality. Factors associated with failure to improve mortality rates can also be a result of an improper combination of medications. This is because the combination of a statin, aspirin, and B-blockers is associated with the greatest improvement of survival in high risk patients with ischemic heart disease. However, the addition of an angiotensin converting enzyme inhibitor has not been found to confer any additional benefit despite the adjustment for congestive cardiac failure 11. Other factors affecting mortality rates were the delayed time from onset of symptoms to admission, high proportion of heart failure patients, the lack of using fibrin-specific thrombolytic agents, intraaortic balloon pump and invasive strategies for revascularization, inappropriate care of lifethreatening complications and an inadequate coronary care unit. Our results suggest that approaches to prevention of ACS and reduction of morbidity and mortality due to ACS can be based on improving care in patients with currently known risk factors, early recognition of symptoms, and an EMS [Emergency Medical Services] system to shorten the time of definite treatment and better management of complications by medical teams. Improving the guidelines for management of ACS in Phrae hospital and the establishment of a coronary care unit would improve the management of ACS in Phrae hospital and should be developed. The TIMI risk score 12,13 should be readily applied at the bedside at the time of hospital presentation, and poor prognostic patients should be recognized for early referred to centers with interventional cardiology facilities. Our study has several potential limitations. 1. and No diagnoses were not strictly validated. 2.All ACS patients in Phrae hospital may not be reported. 3. Other risk factors were not recorded. 4. In cardiogenic shock and those with heart failure the outcomes cannot be identified because we could not differentiate whether it was present at initial presentation or developed in the hospital. 5. The Killip classification was not used in heart failure patients. Conclusion The results of this study provide additional data concerning ACS in the rural population where there are drug limitations and restricted access to new treatment strategies. There were high in-hospital mortality and complication rates. These findings suggest that there should be further development of the guidelines for ACS management, acute management of complications and appropriate early referral for patients with ACS admitted to Phrae hospital. References 1. Roger WJ, Bowlby LJ, Chandra NC et al. United States [199 to 1993] Observations from the National Registry of Myocardial Inf arction. Circulation 1994;9: Philippe Gabriel Steg, Robert J, Goldberg, et al. Baseline Characteristics, Management Practices and In-Hospital Outcomes of Patients Hospital with Acute Coronary Syndromes in the Global Registry of Acute Coronary Events [GRACE]. Am J Cardiol 22; 9: Chaiteraphan S, Ngam U-kos, Laothavorn P et al. Acute myocardial infarction: A collaborative study of 1,541 cases from four medical centers in Thailand. J Med Assoc Thai 1984; 67: Thanasak Patmuk. Acute myocardial infarction in Ratchaburi Hospital.Thai Heart J 24;14[1]: Thai acute coronary syndrome registry [Data 1 August 22 to 31 July 24]. The Heart Association of Thailand under The Royal Patronage.[Available from Http//Library.hsri.or.th.] 6. Braunwald E, Antman EM, Beasley JW et al.acc/aha 22 Guideline Update for the Management of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction.A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines ( Committee on the Management of Patients with Unstable angina). J Am Coll Cardiol 22: 4[7]; Antman EM, Anbe DT, Armstrong PW et al.acc/aha Guidelines for the Management of Patients with ST-Elevation Myocardial Inf arction- Executive Summary. A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol 24;44: Battler A, Brindis R, et al. American College of Cardiology key data elements and definitions for measuring the clinical management and outcome of patients with acute coronary syndromes: A re port of the American College of Cardiology Task Force on clinical data standards (Acute coronary syndromes writing committee). J Am Coll Cardiol 21;38: Granger CB, Steg PG, Peterson E et al. Medication performance measures and mortality following acute coronary syndromes. Am J Med 25;118: Yusuf S, Hawken S, Qunpuu S et al. Effect of potentially modifiable risk factor associated with myocardial infarction in 52 countries [the INTERHEART study]: case-control study. Lancet 24;364: Hippisley-Cox J, Coupland C. Effect of combinations of drugs on all cause mortality in patients with ischemic heart disease: nested case-control analysis. BMJ 25;33: Morrow DA, Antman EM, Charlesworth A et al. TIMI Risk Score f or ST-Elevation Myocardial Infarction: A Convenient, Bedside, Clini cal Score for Risk Assessment at Presentation: An Intravenous npa for Treatment of Infarcting Myocardium Early II trial Substudy. Circulation 2;12: Antman EM, Cohen M, Bernink PJ, et al.the TIMI risk score for unstable/non-st elevation MI: A method for prognostication and therapeutic decision making.jama 2;284: THAI HEART JOURNAL Vol. 19 No.3 July 26

9 14 ก ก ก ก ก,., ก ก, : ก ก ก ก ก ก ก ก ก : ก ก ก ก 2548 ก ก : ก ก 28, 48.1% ST-segment elevation [], 51.9% No ST-segment elevation [No] ก non STsegment elevation 11.5% ก [unstable angina] 4.4%. 57.7% กก 65, 45.2% 87% ก ก. ก 6%, 23% ก 3 ก, 35% 3 ก ก. 9.6%, ก ก 15.% กก ก ก No 4.6%, p-value =.17 ก ก ก [cardiogenic shock], ventricular arrhythmia, complete heart block ก [systolic BP] ก ก 1 ก ก [congestive heart failure] ก No ก ก ก กก 75, ก ก ก ก : ก ก ก ก. ก ก ก. ก ก ก ก ก, ก ก THAI HEART JOURNAL Vol. 19 No.3 July 26