• Mortality risk of STEMI patients shows high variability -need for scoring systems • time-consuming imaging/laboratory studies, and findings/results of the coronary

intervention (“discharge models”) • most common variables used in existing models are age

• Killip class • heart rate • SBP at admission • ECG localization of the infarction • ischemia time • GFR • occurrence of TVD • final TIMI flow

Introduction

APEX AMI mortality risk model

GRACE risk predictor (GRACE score 2.0)

zwolle score

• Previous risk models have not considered access site as a candidate predictor • existing scoring systems were constructed using low risk populations

of trials excluding cardiogenic shock

• single center• prospective cohort study • predicting 30-day mortality of STEMI patients undergoing PPCI.Study Design• 1,255 consecutive STEMI patients treated with PPCI • September 2007 through December 2011• followed-up for a minimum of one year • Role of eight candidate variables readily available at or soon after presentation • 30-day all-cause mortality using logistic regression

Methods

continuous parameters

• Age• onset-to-door (ischemia) time• heart rate • SBP at admission

categorical variables

• Gender• ECG localization of the infarction• need for life support on or prior to admission• vascular access site

ALPHAAge,

Life support,

Pressure,

Heart rate,

Access site

1. development (September 2007 through March 2010, 750 patients, ≈60%)

2. validation (between April 2010 and December 2011, 505 cases, ≈40%)

• UFH (70 IU/kg, for PCI with planned use of the glycoprotein IIb/IIIa receptor inhibitor eptifibatide or 100 IU/kg, for PCI without planned use of eptifibatide) • pretreated with ASA and a loading dose of 600 mg clopidogrel, i.e.

none of them received prasugrel or ticagrelor• Interventional cardiologists were high-volume operators (>200

PCIs/year) skilled in both femoral and radial techniques.

Primary PCI

• 30-day mortality was independently associated with older age, faster heart rate, need for life support on or prior to admission, and femoral access while it was inversely related to SBP as a non-linear parameter • High discriminatory power and good calibration

Discussion

• first STEMI risk model that employs access site as a variable. • mortality benefit of transradial PPCI -RCT (RIVAL (RadIal Vs. femorAL)

trial, RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) trial, MORTAL (Mortality benefit Of Reduced Transfusion after percutaneous intervention via Arm or Leg) trial ) • decrease in all-cause mortality with radial access could be mediated

by a reduction of bleeding events• European guidelines favor transradial access in both STEMI and non-

STE ACS patients

• ALPHA employs only five immediately available and easy-to-measure variables enabling risk assessment at presentation.• Despite its simplicity, ALPHA achieved the numerically highest c-index

for 30-day mortality(validated c-statistic: 0.87) and its discriminatory power was stable over multiple time points

• prospective registry data of a single institution. • may not be valid for populations/centers of other geographic regions

with different baseline risk, resources, and experience. • limited sample size of the validation cohort did not allow the

detection of some clinically potentially relevant differences during comparative validation• exclusively used clopidogrel

Limitations