China PEACE risk estimation tool for in-hospital death from acute myocardial infarction: an early risk classification tree for decisions about fibrinolytic therapy

OBJECTIVES: As the predominant approach to acute reperfusion for ST segment elevation myocardial infarction (STEMI) in many countries, fibrinolytic therapy provides a relative risk reduction for death of ∼16% across the range of baseline risk. For patients with low baseline mortality risk, fibrinolytic therapy may therefore provide little benefit, which may be offset by the risk of major bleeding. We aimed to construct a tool to determine if it is possible to identify a low-risk group among fibrinolytic therapy-eligible patients. DESIGN: Cross-sectional study. SETTING: The China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) study includes a nationally representative retrospective sample of patients admitted with acute myocardial infarction (AMI) in 162 hospitals. PARTICIPANTS: 3741 patients with STEMI who were fibrinolytic-eligible but did not receive reperfusion therapy. MAIN OUTCOME MEASURES: In-hospital mortality, which was defined as a composite of death occurring within hospitalisation or withdrawal from treatment due to a terminal status at discharge. RESULTS: In the study cohort, the in-hospital mortality was 14.7%. In the derivation cohort and the validation cohort, the combination of systolic blood pressure (≥100 mm Hg), age (<60 years old) and gender (male) identified one-fifth of the cohort with an average mortality rate of <3.0%. Half of this low risk group—those with non-anterior AMI—had an average in-hospital death risk of 1.5%. CONCLUSIONS: Nearly, one in five patients with STEMI who are eligible for fibrinolytic therapy are at a low risk for in-hospital death. Three simple factors available at the time of presentation can identify these individuals and support decision-making about the use of fibrinolytic therapy. TRIAL REGISTRATION NUMBER: NCT01624883.