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Prognosis in the Thrombolysis in Myocardial Ischemia III Registry according to the Braunwald unstable angina pectoris classification

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Abstract

The unstable angina pectoris (UAP) classification proposed by Braunwald in 1989, although often used, has never been validated in a large, prospective multicenter study in which all subgroups of patients were included. Patients with UAP or non–ST-elevation myocardial infarction (NSTEMI) were enrolled in the Thrombolysis In Myocardial Ischemia III Registry and classified according to the Braunwald classification for UAP. Clinical end points were compared at 6 weeks and 1 year. Of 3,318 patients, those with primary UAP had lower rates of recurrent myocardial infarction (MI) or death when compared with patients with secondary UAP and post-MI UAP at 6 weeks (4.1% vs 6.4% vs 13.4%, respectively; p <0.001) and 1 year (9.7% vs 16.7% vs 19.7%; p <0.001). Recurrent ischemia at 6 weeks followed the same gradient (13.2% vs 18.5% vs 20.8%; p <0.001). Patients with secondary UAP had similar extent of disease at angiography as primary UAP. Patients with nonresting UAP had lower rates of death or MI than patients with UAP at rest (3.0% vs 5.6%, p = 0.011 at 6 weeks, and 8.2% vs 12.5%, p = 0.004 at 1 year). Patients with ST-segment deviation and those who had received prior antianginal medical treatment also had worse outcomes. Thus, the Braunwald classification of UAP predicts prognosis with secondary UAP, post-MI UAP, and patients with pain at rest who have a higher risk for death or recurrent cardiac events. Given their high risk for adverse events, patients with secondary UAP should be treated aggressively.

Section snippets

Methods

The details of the Thrombolysis in Myocardial Ischemia III Registry have been previously reported.10 Briefly, patients admitted between October 1990 and April 1993 with a diagnosis of UAP or NSTEMI at 14 tertiary care hospitals in the United States and Canada were screened for inclusion on an enumeration roster. Inclusion criteria were an episode of either resting or exertional pain presumed to be ischemic in origin, lasting >5 minutes, occurring within 96 hours before enrollment. If

Results

Overall, in the Thrombolysis in Myocardial Ischemia III Registry, the mean age was 61.5 years, 58.3% of patients were men, 51.0% had hypertension, 24.2% had diabetes mellitus, and 21.2% of patients were determined to have a NSTEMI at presentation.10

Each of the Braunwald subgroups was well represented in the registry. Two thousand two hundred forty-eight patients (73.7%) had primary UAP, 708 (21.3%) had secondary UAP, and 164 (4.9%) had post-MI UAP. Most of the patients (2,563 patients, 77.3%)

Discussion

The principal goal of the Braunwald classification was to identify patients with a higher risk of adverse events and to provide them with the most appropriate and aggressive care. The Thrombolysis in Myocardial Ischemia III Registry is the first large multicenter study that has prospectively validated all aspects of this classification. As hypothesized, the severity of UAP at presentation and the clinical circumstance leading to UAP successfully predicted prognosis. Specifically, patients who

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