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The Systemic Inflammatory Response Syndrome in Patients With ST-Segment Elevation Myocardial Infarction*

van Diepen, Sean MD, MSc1; Vavalle, John P. MD, MHS2; Newby, L. Kristin MD, MHS2; Clare, Robert MS2; Pieper, Karen S. MS2; Ezekowitz, Justin A. MBBCh, MSc3; Hochman, Judith S. MD4; Mahaffey, Kenneth W. MD2; Armstrong, Paul W. MD3; Granger, Christopher B. MD2

doi: 10.1097/CCM.0b013e31828a67b2
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Objectives: To assess whether systemic inflammatory response syndrome is associated with morbidity and mortality in ST-elevation myocardial infarction.

Design and Setting: Secondary analysis of multicenter randomized controlled trials.

Patients: Complement and reduction of infarct size after angioplasty or lytics project patients (n = 1,903) with ST-elevation myocardial infarction undergoing fibrinolysis or mechanical reperfusion.

Interventions: None

Measurements and Main Results: The prevalence of systemic inflammatory response syndrome was described in the 1,186 patients (64.4%) with data available for all systemic inflammatory response syndrome criteria. Using multiple imputations for the 1,843 patients (96.8%) with available endpoints, we compared the 90-day prevalence of death, shock, heart failure, or stroke between patients with and without systemic inflammatory response syndrome at presentation and at 24 hours post admission. Systemic inflammatory response syndrome was defined as ≥ 2 of 1) heart rate > 90 beats/min, 2) respiratory rate > 20 breaths/min, 3) body temperature > 38 or < 36°C, or 4) leukocyte count > 12 or < 4 × 109/L. At presentation, 25.0% of patients met systemic inflammatory response syndrome criteria; at 24 hours, 8.1% of patients met systemic inflammatory response syndrome criteria. The primary outcome was more frequent among patients with systemic inflammatory response syndrome at presentation (31.0% vs 16.7%; adjusted hazard ratio, 1.78 [95% CI, 1.35–2.34]; p < 0.001) and at 24 hours (36.7% vs 11.1%; adjusted hazard ratio, 2.84 [95% CI, 2.03–3.97]; p < 0.001). Mortality at 90 days was also higher among patients with systemic inflammatory response syndrome at either time point. Each additional systemic inflammatory response syndrome criterion was independently associated with 90-day outcomes at the time of presentation (adjusted hazard ratio, 1.41 per systemic inflammatory response syndrome criteria [95% CI, 1.24–1.61]; p < 0.001) and at 24 hours (adjusted hazard ratio, 1.72 per systemic inflammatory response syndrome criteria [95% CI, 1.47–2.01]; p < 0.001).

Conclusion: The diagnosis of systemic inflammatory response syndrome and the cumulative number of systemic inflammatory response syndrome criteria were independently associated with 90-day clinical outcomes in a population of patients with ST-elevation myocardial infarction. The independent association of this simple composite measure of the inflammatory response with outcomes underscores the importance of the clinical inflammatory response in ST-elevation myocardial infarction.

1Division of Cardiology and Critical Care, University of Alberta, Edmonton, Alberta, Canada.

2Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.

3Cardiovascular Clinical Research Center, New York University School of Medicine, New York, NY.

* See also p. 2223.

This work was performed at the Duke Clinical Research Institute.

This work was derived from the COMMA and COMPLY trials that were supported, in part, by Procter & Gamble Pharmaceutical (Cincinnati, OH) and Alexion Pharmaceuticals (Cheshire, CT).

Disclosures for Drs. Newby, Mahaffey, and Granger are publically available and listed at https://www.dcri.org/about-us/conflict-of-interest. Dr. Hochman served as the national coordinator and as a steering committee member for the STABILITY Trial (Glaxo Smith Kline) and as a steering committee member for SOLID-TIMI 52 (Glaxo Smith Kline), and Arbor Pharmaceuticals has provided Nitro-Spray to some ISCHEMIA trial enrolling sites. Dr. Armstrong received research grants from Procter & Gamble Pharmaceutical and Alexion Pharmaceuticals. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: sv9@ualberta.ca

© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins