Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Risk factors for adverse outcomes after ST-elevation myocardial infarction

Joseph S Alpert, MD
Pamela S Douglas, MD
Peter WF Wilson, MD
Michael Simons, MD
Jeffrey A Breall, MD, PhD
Section Editors
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Patricia A Pellikka, MD, FACC, FAHA, FASE
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Christopher P Cannon, MD
Allan S Jaffe, MD
Deputy Editor
Gordon M Saperia, MD, FACC


Patients with ST-elevation myocardial infarction (STEMI) should undergo risk stratification soon after presentation. This process has two components:

Early in-hospital identification of patients at increased risk for recurrent ischemic events.

Identification of patients after a myocardial infarction (MI) who are at increased risk for arrhythmic or nonarrhythmic death.

The individual risk factors that influence prognosis will be discussed here. The use of these risk factors in risk prediction models and the prognosis of patients after MI are discussed separately. (See "Risk stratification after acute ST-elevation myocardial infarction", section on 'Early risk stratification' and "Prognosis after myocardial infarction".)

Although there is significant overlap in the risk factors for acute non-ST elevation coronary syndrome (NSTEACS) and ST-elevation myocardial infarction (STEMI), they are presented separately, in part because the risk prediction models for STEMI and NSTEACS differ in their components. (See "Risk factors for adverse outcomes after non-ST elevation acute coronary syndromes".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Feb 2017. | This topic last updated: Wed Mar 08 00:00:00 GMT+00:00 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Canto JG, Kiefe CI, Rogers WJ, et al. Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction. JAMA 2011; 306:2120.
  2. Shlipak MG, Heidenreich PA, Noguchi H, et al. Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients. Ann Intern Med 2002; 137:555.
  3. Anavekar NS, McMurray JJ, Velazquez EJ, et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med 2004; 351:1285.
  4. Wright RS, Reeder GS, Herzog CA, et al. Acute myocardial infarction and renal dysfunction: a high-risk combination. Ann Intern Med 2002; 137:563.
  5. McCullough PA, Nowak RM, Foreback C, et al. Emergency evaluation of chest pain in patients with advanced kidney disease. Arch Intern Med 2002; 162:2464.
  6. Narins CR, Zareba W, Moss AJ, et al. Relationship between intermittent claudication, inflammation, thrombosis, and recurrent cardiac events among survivors of myocardial infarction. Arch Intern Med 2004; 164:440.
  7. Bucholz EM, Krumholz HA, Krumholz HM. Underweight, Markers of Cachexia, and Mortality in Acute Myocardial Infarction: A Prospective Cohort Study of Elderly Medicare Beneficiaries. PLoS Med 2016; 13:e1001998.
  8. Becker RC, Burns M, Gore JM, et al. Early assessment and in-hospital management of patients with acute myocardial infarction at increased risk for adverse outcomes: a nationwide perspective of current clinical practice. The National Registry of Myocardial Infarction (NRMI-2) Participants. Am Heart J 1998; 135:786.
  9. Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol 1967; 20:457.
  10. Wu AH, Parsons L, Every NR, et al. Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2). J Am Coll Cardiol 2002; 40:1389.
  11. Steg PG, Dabbous OH, Feldman LJ, et al. Determinants and prognostic impact of heart failure complicating acute coronary syndromes: observations from the Global Registry of Acute Coronary Events (GRACE). Circulation 2004; 109:494.
  12. Califf RM, Pieper KS, Lee KL, et al. Prediction of 1-year survival after thrombolysis for acute myocardial infarction in the global utilization of streptokinase and TPA for occluded coronary arteries trial. Circulation 2000; 101:2231.
  13. Morrow DA, Antman EM, Charlesworth A, et al. TIMI risk score for ST-elevation myocardial infarction: A convenient, bedside, clinical score for risk assessment at presentation: An intravenous nPA for treatment of infarcting myocardium early II trial substudy. Circulation 2000; 102:2031.
  14. De Luca G, Suryapranata H, van 't Hof AW, et al. Prognostic assessment of patients with acute myocardial infarction treated with primary angioplasty: implications for early discharge. Circulation 2004; 109:2737.
  15. Halkin A, Singh M, Nikolsky E, et al. Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score. J Am Coll Cardiol 2005; 45:1397.
  16. DeGeare VS, Boura JA, Grines LL, et al. Predictive value of the Killip classification in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol 2001; 87:1035.
  17. De Luca G, van 't Hof AW, de Boer MJ, et al. Impaired myocardial perfusion is a major explanation of the poor outcome observed in patients undergoing primary angioplasty for ST-segment-elevation myocardial infarction and signs of heart failure. Circulation 2004; 109:958.
  18. Crimm A, Severance HW Jr, Coffey K, et al. Prognostic significance of isolated sinus tachycardia during first three days of acute myocardial infarction. Am J Med 1984; 76:983.
  19. Pizzetti F, Turazza FM, Franzosi MG, et al. Incidence and prognostic significance of atrial fibrillation in acute myocardial infarction: the GISSI-3 data. Heart 2001; 86:527.
  20. Jabre P, Jouven X, Adnet F, et al. Atrial fibrillation and death after myocardial infarction: a community study. Circulation 2011; 123:2094.
  21. Poçi D, Hartford M, Karlsson T, et al. Role of the CHADS2 score in acute coronary syndromes: risk of subsequent death or stroke in patients with and without atrial fibrillation. Chest 2012; 141:1431.
  22. Betriu A, Califf RM, Bosch X, et al. Recurrent ischemia after thrombolysis: importance of associated clinical findings. GUSTO-I Investigators. Global Utilization of Streptokinase and t-PA [tissue-plasminogen activator] for Occluded Coronary Arteries. J Am Coll Cardiol 1998; 31:94.
  23. Armstrong PW, Fu Y, Chang WC, et al. Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators. Circulation 1998; 98:1860.
  24. GISSI-3 APPI Study Group. Early and six-month outcome in patients with angina pectoris early after acute myocardial infarction (the GISSI-3 APPI [angina precoce post-infarto] study). Am J Cardiol 1996; 78:1191.
  25. Gottlieb SO, Gottlieb SH, Achuff SC, et al. Silent ischemia on Holter monitoring predicts mortality in high-risk postinfarction patients. JAMA 1988; 259:1030.
  26. Deedwania PC. Asymptomatic ischemia during predischarge Holter monitoring predicts poor prognosis in the postinfarction period. Am J Cardiol 1993; 71:859.
  27. Ottani F, Galvani M, Nicolini FA, et al. Elevated cardiac troponin levels predict the risk of adverse outcome in patients with acute coronary syndromes. Am Heart J 2000; 140:917.
  28. Kanna M, Nonogi H, Sumida H, et al. Usefulness of serum troponin T levels on day three or four in predicting survival after acute myocardial infarction. Am J Cardiol 2001; 87:294.
  29. Giannitsis E, Müller-Bardorff M, Lehrke S, et al. Admission troponin T level predicts clinical outcomes, TIMI flow, and myocardial tissue perfusion after primary percutaneous intervention for acute ST-segment elevation myocardial infarction. Circulation 2001; 104:630.
  30. Ohman EM, Armstrong PW, White HD, et al. Risk stratification with a point-of-care cardiac troponin T test in acute myocardial infarction. GUSTOIII Investigators. Global Use of Strategies To Open Occluded Coronary Arteries. Am J Cardiol 1999; 84:1281.
  31. Omland T, Aakvaag A, Bonarjee VV, et al. Plasma brain natriuretic peptide as an indicator of left ventricular systolic function and long-term survival after acute myocardial infarction. Comparison with plasma atrial natriuretic peptide and N-terminal proatrial natriuretic peptide. Circulation 1996; 93:1963.
  32. Richards AM, Nicholls MG, Yandle TG, et al. Plasma N-terminal pro-brain natriuretic peptide and adrenomedullin: new neurohormonal predictors of left ventricular function and prognosis after myocardial infarction. Circulation 1998; 97:1921.
  33. Omland T, Persson A, Ng L, et al. N-terminal pro-B-type natriuretic peptide and long-term mortality in acute coronary syndromes. Circulation 2002; 106:2913.
  34. Richards AM, Nicholls MG, Espiner EA, et al. B-type natriuretic peptides and ejection fraction for prognosis after myocardial infarction. Circulation 2003; 107:2786.
  35. Tapanainen JM, Lindgren KS, Mäkikallio TH, et al. Natriuretic peptides as predictors of non-sudden and sudden cardiac death after acute myocardial infarction in the beta-blocking era. J Am Coll Cardiol 2004; 43:757.
  36. Mega JL, Morrow DA, De Lemos JA, et al. B-type natriuretic peptide at presentation and prognosis in patients with ST-segment elevation myocardial infarction: an ENTIRE-TIMI-23 substudy. J Am Coll Cardiol 2004; 44:335.
  37. Khan SQ, Quinn P, Davies JE, Ng LL. N-terminal pro-B-type natriuretic peptide is better than TIMI risk score at predicting death after acute myocardial infarction. Heart 2008; 94:40.
  38. Goyal A, Spertus JA, Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA 2012; 307:157.
  39. Grodzinsky A, Goyal A, Gosch K, et al. Prevalence and Prognosis of Hyperkalemia in Patients with Acute Myocardial Infarction. Am J Med 2016; 129:858.
  40. Madjid M, Awan I, Willerson JT, Casscells SW. Leukocyte count and coronary heart disease: implications for risk assessment. J Am Coll Cardiol 2004; 44:1945.
  41. Barron HV, Cannon CP, Murphy SA, et al. Association between white blood cell count, epicardial blood flow, myocardial perfusion, and clinical outcomes in the setting of acute myocardial infarction: a thrombolysis in myocardial infarction 10 substudy. Circulation 2000; 102:2329.
  42. Cannon CP, McCabe CH, Wilcox RG, et al. Association of white blood cell count with increased mortality in acute myocardial infarction and unstable angina pectoris. OPUS-TIMI 16 Investigators. Am J Cardiol 2001; 87:636.
  43. Barron HV, Harr SD, Radford MJ, et al. The association between white blood cell count and acute myocardial infarction mortality in patients > or =65 years of age: findings from the cooperative cardiovascular project. J Am Coll Cardiol 2001; 38:1654.
  44. Grau AJ, Boddy AW, Dukovic DA, et al. Leukocyte count as an independent predictor of recurrent ischemic events. Stroke 2004; 35:1147.
  45. Patel MR, Mahaffey KW, Armstrong PW, et al. Prognostic usefulness of white blood cell count and temperature in acute myocardial infarction (from the CARDINAL Trial). Am J Cardiol 2005; 95:614.
  46. Sabatine MS, Morrow DA, Giugliano RP, et al. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation 2005; 111:2042.
  47. Aronson D, Suleiman M, Agmon Y, et al. Changes in haemoglobin levels during hospital course and long-term outcome after acute myocardial infarction. Eur Heart J 2007; 28:1289.
  48. Beygui F, Collet JP, Benoliel JJ, et al. High plasma aldosterone levels on admission are associated with death in patients presenting with acute ST-elevation myocardial infarction. Circulation 2006; 114:2604.
  49. Kobayashi N, Maehara A, Brener SJ, et al. Usefulness of the Left Anterior Descending Coronary Artery Wrapping Around the Left Ventricular Apex to Predict Adverse Clinical Outcomes in Patients With Anterior Wall ST-Segment Elevation Myocardial Infarction (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction Trial). Am J Cardiol 2015; 116:1658.
  50. Tisminetzky M, McManus DD, Erskine N, et al. Thirty-day Hospital Readmissions in Patients with Non-ST-segment Elevation Acute Myocardial Infarction. Am J Med 2015; 128:760.
  51. Dreyer RP, Ranasinghe I, Wang Y, et al. Sex Differences in the Rate, Timing, and Principal Diagnoses of 30-Day Readmissions in Younger Patients with Acute Myocardial Infarction. Circulation 2015; 132:158.
  52. Hess CN, Wang TY, McCoy LA, et al. Unplanned Inpatient and Observation Rehospitalizations After Acute Myocardial Infarction: Insights From the Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome (TRANSLATE-ACS) Study. Circulation 2016; 133:493.