Risk Stratifying AMI

While we need to work harder to prevent CAD, with our many prone attacks, like primary prevention strategies (diet, exercise, maintaining ideal weight, control BP, control diabetes, stop smoke, lower cholesterol), it is also important, especially for us in a developing country, to risk stratify heart attacks so that the invasive mode of therapy be applied to those with the greatest risk of dying first. This will allow us, in the developing country to better use our resources.

To this end, the recent paper in the Lancet by the group in Greenlane, NZ, led by Dr Harvey White, is particularly important. The paper that appeared in Lancet Jun 24th 2006 is entitled "Initial Q waves accompanying ST elevation at presentation of acute myocardial infarction and 30-day mortality in patients given streptokinase therapy, an analysis of HERO 2". This study, in a country more like us than the USA, concluded that the presence of Q wave in the presenting ECG seems to suggest a higher 30-day mortality.

The study looked at a population of 15,200 patients, 10,244 patients of which had Q wave, at pesentation, while 4078 patients did not. Using multi-variate analysis, only the presence of intial Q waves, seem to an impact on 30 days mortality. What it may mean, is that patients who had hemodynamic instability following an AMI and patients who had initial Q waves at the initial ECG at presentation, are at higher risk of dying the early 30 days, and must therefore require more aggressive management, like coronary angiogram, angioplasty or even bypass surgery.

Those without the Qwaves, may be treated with IV-lytic therapy and usual medical therapy including anti-platelet therapy, "statins", and ACE-I.