Prediction of 30-day mortality in older patients with a first acute myocardial infarction

This study sought predictors of mortality in patients aged >or=75 years with a first ST-segment elevation myocardial infarction (STEMI) and evaluated the validity of the GUSTO-I and TIMI risk models. Clinical variables, treatment and mortality data from 433 consecutive patients were collected. Univariable and multivariable logistic regression analyses were applied to identify baseline factors associated with 30-day mortality. Subsequently a model predicting 30-day mortality was created and compared with the performance of the GUSTO-I and TIMI models. After adjustment, a higher Killip class was the most important predictor (OR 16.1; 95% CI 5.7-45.6). Elevated heart rate, longer time delay to admission, hyperglycemia and older age were also associated with increased risk. Patients with hypercholesterolemia had a significantly lower risk (OR 0.46; 95% CI 0.24-0.86). Discrimination (c-statistic 0.79, 95% CI 0.75-0.84) and calibration (Hosmer-Lemeshow 6, p = 0.5) of our model were good. The GUSTO-I and TIMI risk scores produced adequate discrimination within our dataset (c-statistic 0.76, 95% CI 0.71-0.81, and c-statistic 0.77, 95% CI 0.72-0.82, respectively), but calibration was not satisfactory (HL 21.8, p = 0.005 for GUSTO-I, and HL 20.6, p = 0.008 for TIMI). In conclusion, short-term mortality in elderly patients with a first STEMI depends most importantly on initial clinical and hemodynamic status. The GUSTO-I and TIMI models are insufficiently adequate for providing an exact estimate of 30-day mortality risk.

Infective endocarditis: Absence of microbiological diagnosis is an independent predictor of inhospital mortality

Infective endocarditis (IE) is associated with high inhospital mortality. New microbiological diagnostic techniques have reduced the proportion of patients without etiological diagnosis, but in a significant number of patients the cause is still unknown. Our aim was to study the association of the absence of microbiological diagnosis with in-hospital prognosis. Prospective cohort of 2000 consecutive patients with IE. Data were collected in 26 Spanish hospitals. Modified Duke criteria were used to diagnose patients with suspected IE. A total of 290 patients (14.8%) had negative blood cultures. Etiological diagnosis was achieved with other methods (polymerase chain reaction, serology and other cultures) in 121 (6.1%). Finally, there were 175 patients (8.8%) without microbiological diagnosis (Group A) and 1825 with diagnosis (Group B). In-hospital mortality occurred in 58 patients in Group A (33.1%) vs. 487 (26.7%) in Group B, p = 0.07. Patients in Group A had a lower risk profile than those in Group B, with less comorbidity (Charlson index 1.9 ± 2.0 vs. 2.3 ± 2.1, p = 0.03) and lower surgical risk (EuroSCORE 23.6 ± 21.8 vs. 29.6 ± 25.2, p = 0.02). However they presented heart failure more frequently (53% vs. 40%, p = 0.005). Multivariate analysis showed that the absence of microbiological diagnosis was an independent predictor of inhospital mortality (odds ratio 1.8, 95% Confidence Interval 1.1–2.9, p = 0.016). Approximately 9% of patients with IE had no microbiological diagnosis. Absence of microbiological diagnosis was an independent predictor of inhospital mortality.