European Heart Journal (1996) 17, 1532-1537
Long-term prognosis of patients after a Q wave
compared with a non-Q wave first acute myocardial
infarction
Data from the SPRINT Registry
S. Behar, M. Haim, H. Hod, R. Kornowski, H. Reicher-Reiss, M. Zion,
E. Kaplinsky, E. Abinader, A. Palant, Y. Kishon, L. Reisin, I. Zahavi, U. Goldbourt
and the SPRINT Study Group
Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, Israel
Results Five hundred and eighty patients (14%) had first
myocardial infarctions of the non-Q wave type and 3457 of
the Q wave type. Hospital mortality was significantly higher
in patients with a Q wave (10%) than those with a non-Q
wave myocardial infarction (7%) (/><005). One year postdischarge, non-fatal reinfarction and mortality rates were
Introduction
Although several recent publications have convincingly
shown that patients with a non-Q wave acute myocardial infarction enjoy a better in-hospital prognosis
than patients with a Q wave infarction, the long-term
outcome is similar for both'1"101. In a few studies,
however, patients with a non-Q wave infarction experienced worse prognosis than patients with a Q wave
infarction 1 " 12 ', but the patient numbers were small,
first and recurrent myocardial infarctions were combined and in most follow-up was relatively short'6"81.
Revision submitted 16 January 1996, and accepted 15 February
1996.
Correspondence: S. Behar. MD, Heart Institute, Chaim Sheba
Medical Center, Tel Hashomer, 52621, Israel.
0195-668X796/101532 + 08 $18.00/0
comparable in patients with Q wave (4% and 7%) and
non-Q wave myocardial infarctions (4% and 7% respectively). Similarly, 5 to 10 year post-discharge mortality rates
were equally high in patients with a non-Q wave (26% and
44%) as in those with afirstepisode of a Q wave myocardial
infarction (22% and 40% respectively).
Conclusions Patients with a first non-Q wave acute myocardial infarction exhibited relatively better in-hospital survival than counterparts with a first Q wave infarction, but
the advantage did not persist after discharge. Patients with
a non-Q wave infarction deserve particular attention as
their post-discharge mortality risk is similar to counterparts
with a first Q wave myocardial infarction.
(Eur Heart J 1996; 17: 1532-1537)
Key Words: Non-Q wave MI, prognosis.
The present study compares 10 year survival among
4037 patients with a first myocardial infarction of the Q
and non-Q wave types. These patients were hospitalized
in 13 coronary care units in Israel in the early 1980s and
were followed for vital status up to mid-1992.
Methods
Between August 1981 and July 1983, 5839 consecutive
patients who sustained an acute myocardial infarction
were hospitalized in 13 coronary care units in Israel and
screened for inclusion into the Secondary Prevention
Reinfarction Israeli Nifedipine Trial (SPRINT)1'31.
Demographic and medical data from hospital
records and 1 year post-discharge follow-up were collected for all consecutive myocardial infarction patients
(n = 5839).
© 1996 The European Society of Cardiology
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Objective, design and patients Between August 1981
and July 1983, 5839 consecutive myocardial infarction
patients were hospitalized in 13 coronary care units in
Israel. The present study examines 10 year survival among
4037 consecutive patients with a first myocardial infarction
with either Q or non-Q waves. Demographic and medical
data were collected from hospital records, and 1 year
clinical follow-up was complete for 99% of hospital survivors. Mortality follow-up was extended to June 1992 (mean
10 years of follow-up).
Q wave vs non-Q wave MI
J533
Table 1 Characteristics and hospital course of patients with a first Q and a first
non-Q wave acute myocardial infarction
Non-Q wave
(n = 580)
Q wave
(n = 3457)
n
Men
Mean age (years)
History
AP
Hypertension
Diabetes mellitus
PVD
CVA
Admission
Chest X-ray:
Cardiomegaly
Pulmonary congestion or oedema
Killip class
I
II
III
n
P value
%
2592
75
61-4 ( ± 10-9)
66
381
62-7 ( ± 1 1 1)
00001
0-01
1387
1375
693
190
133
41
40
20
6
4
277
240
127
42
21
49
42
22
7
4
00001
ns
ns
ns
ns
813
721
24
21
147
96
26
17
ns
0-02
ns
2819
501
89
21
82
15
3
2
480
80
13
7
83
14
2
1
1731
1587
138
1
50
46
4
—
230
187
130
33
40
32
22
6
149
619
179
448
340
687
135
4
18
5
13
10
20
4
18
81
23
59
37
73
20
3
14
4
10
6
13
3
ns
002
ns
006
0008
00001
ns
2023
1577
471
60
46
14
291
184
39
52
32
7
00001
00001
0-0001
00001
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IV
MI location
Anterior
Inferior
Lateral
Undetermined
Complications
CA
VT
VF
PAF
Advanced AV block
CHF
Cardiogenic shock
Enzymes >4 x normal
CK
AST
LDH
%
AP=angina pectoris; AST=aspartate aminotransferase; AVB=atrio ventricular block; CA =
cardiac arrest; CAF=chronic atrial fibrillation; CHF = congestive heart failure; CK = creatine
kinase; CVA = cerebrovascular accident; LDH = lactate dehydrogenase; PAF = paroxysmal atrial
fibrillation; PVD = penpheral vascular disease; VT=ventricular tachycardia; VF = ventricular
fibrillation.
Mortality follow-up (9-5-11 years, mean 10
years) was complete for 99% of hospital survivors
through the Israeli Population Register.
Definition of Q and non-Q wave infarction
The diagnosis of Q and non-Q wave myocardial
infarction was based on serial ECGs obtained during
hospitalization in the coronary care unit. Patients with
non-Q wave myocardial infarction had typical clinical
symptoms, high serum cardiac enzyme levels and
only ST segment and/or T wave changes on the ECG.
Patients with Q wave infarctions presented with typical
symptoms lasting ^30 min, had elevated serum levels of
cardiac enzymes and developed Q waves or QS patterns
during hospitalization. The Minnesota Code'14' was used
for ECG interpretation.
In order to avoid the impact of previous myocardial infarction on outcome, only patients with a first
myocardial infarction (n=4314) were included in the
present study. Two hundred and twelve patients who
died within 24 h of admission were excluded from the
analysis as the exact type of their myocardial infarction
(Q or non-Q) could not be determined with certainty.
Sixty-five other patients were excluded because of
missing data. Thus 4037 patients with a first myocardial
infarction and who survived for 24 h were included in
the present analysis.
Thrombolytic therapy and invasive coronary
procedures were not in use during the index hospitalization (1981-83).
Eur Heart J, Vol. 17, October 1996
1534 S. Behar et al.
Statistical analysis
The SAS software1151 was used for statistical analysis.
Proportions were compared using the x2 test.
The pooled relative risk of hospital mortality
(and its confidence interval) for Q compared with non
Q-myocardial infarction, controlling for age, gender,
congestive heart failure, diabetes, angina, and participation in the SPRINT trial was calculated using the
Mantel-Haenszel test (procedure FREQ with option
CMH).
For the analysis of 10 year mortality, adjusted
relative risk of death was estimated for in-hospital
survivors by the Cox proportional hazards model
(PHREG of SAS procedure). Adjustment was made
for the same variables used for estimation of hospital
mortality.
The Kaplan-Meier method'16' was used for
producing survival curves for Q wave and non-Q wave
patients during the follow-up period (LIFETEST
procedure).
Table 2 Mortality of patients with a first Q and a first
non-Q wave acute myocardial infarction
Q wave
(n = 3457)
In-hospital*
Post discharge
1 year
5 years
10 years
Non-Q wave
(n = 580)
352
10
43
216
674
7
22
39
38
137
234
1201
IP
value
004
ns
007
005
7
26
44
'Excluding death which occurred within 24 h of admission
Results
Eur Heart J, Vol. 17, October 1996
4
10
11
Figure 1 Survival, curves of patients with a first Q (
compared with a first non-Q (
) wave infarction.
)
Table 3
5
6
7
Time (years)
Treatment on discharge
Q wave
(n = 3105)
Nitrates
Ca-blockers
Digitalis
^-blockers
Antiarrhythmics
Anticoagulants
Antiaggregants
Non-Q wave
(n = <i37)
n
%
n
%
1245
1032
370
485
877
56
531
40
33
12
16
28
2
17
275
182
40
143
111
10
80
51
34
7
27
21
2
15
P
0-0001
ns
0-002
00001
00001
ns
005
those with a Q wave myocardial infarction received
digitalis and antiarrhythmic drugs more often (Table 3).
Figures 2 and 3 depict the distribution of reinfarctions and death over the first year after discharge in
patients with Q and non-Q wave myocardial infarctions.
In patients with a non-Q wave myocardial infarction,
53% of reinfarction occurred during the first 3 months
after discharge (Fig. 2). In the group of patients with a Q
wave myocardial infarction, 49% of the first year postdischarge mortality occurred during the same time
period (Fig. 3). Coronary artery bypass grafting was
rarely performed during the year following hospital
discharge (in five patients with a Q and in two with a
non-Q wave infarction respectively).
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The frequency of non-Q wave myocardial infarction
among the 4037 patients with a first myocardial infarction surviving the first 24 h of hospitalization was 14%
(580/4037), and there was a greater proportion of
women. Except for a higher prevalence of a history of
angina among the group of patients with a non-Q wave
myocardial infarction, and a higher incidence of pulmonary congestion among patients with Q wave myocardial infarction, all other demographic and historical
characteristics were similar (Table 1). Patients with a Q
wave myocardial infarction more frequently developed
major in-hospital complications and had significantly
higher frequencies of anterior and inferior as opposed to
lateral wall myocardial infarction. Very high serum
cardiac enzyme levels, particularly LDH (>4 times
above normal), were more common in patients with a Q
wave myocardial infarction than in those with a non-Q
myocardial infarction (Table 1).
In-hospital mortality was higher among patients
with a Q wave myocardial infarction (10%) than among
counterparts with a non-Q wave infarction (7%, P<005)
(Table 2). However, 1 year post-discharge mortality was
identical (7%) in both groups and after 5 and 10 years of
follow-up, mortality was similar among patients with
a non-Q wave infarction (Table 2). The 1 year postdischarge non-fatal reinfarction rate was 4% both in
patients with a Q wave myocardial infarction and in
those with non-Q wave myocardial infarctions. Figure 1
presents the 10 year survival curves of patients with a Q
compared with those a non-Q wave infarction.
Treatment on discharge from hospital differed in
patients with a Q wave from those with a non-Q wave
myocardial infarction. Specifically, patients with a
non-Q wave myocardial infarction were more frequently
treated with nitrates (51%) and y?-blockers (27%), while
Q wave vs non-Q wave MI
60 r -
Q NQ
1-3
Figure 2
Q NQ
Q NQ
4-6
7 -9
Months
Q
NQ
10-12
Time pattern of reinfarction in the year follow-
ing hospital discharge, Q wave vs non-Q wave infarction.
1535
Short-term prognosis
Q NQ
1-3
Q NQ
4-6
Q NQ
7-9
Q NQ
10-12
Figure 3 Time pattern of death in the year following
hospital discharge, Q wave vs non-Q wave infarction.
The pooled relative risk for in-hospital mortality
for Q compared with non-Q myocardial infarction controlling for age, gender, congestive heart failure on
admission, diabetes, and previous angina was 1-51 (95%
confidence interval: 113-203). After adjustment for the
same variables, the relative risk for 10 year postdischarge mortality was 1-07 (95% confidence interval
0-93-1-24).
The significant difference in hospital mortality of
patients with Q wave (10%) as compared with non-Q
wave myocardial infarctions (7%, /><005) is in accordance with numerous previous studies' 1 ' 2 ' 51819 '. Connolly
and Elveback'21' reported 30-day mortality rates of 18%
and 9% among patients with Q and non-Q wave infarctions, respectively, in a group of 1221 patients with a
first myocardial infarction. In MILIS'171, among 471
patients with a first myocardial infarction, in-hospital
mortality was twice as high (9%) in patients with Q
waves compared to counterparts with non-Q waves
(4%). In a larger study'81, in-hospital mortality was
substantially higher among patients with a first Q wave
myocardial infarction (10%) than among those with
a non-Q wave infarction (4%). In the present study a
first myocardial infarction of the Q wave type was
independently associated with an approximate 50%
adjusted in-hospital increase of risk in comparison with
counterparts with non-Q wave myocardial infarctions.
Discussion
Prevalence of non-Q wave myocardial
infarction
A prevalence of a non-Q wave myocardial infarction of
14% in this study corresponds to the range of non-Q
Long-term prognosis
The results of the present study support the conclusions
of previous studies which showed that long-term
mortality in survivors of non-Q wave myocardial infarctions was no better than in patients with Q wave
Eur Heart J, Vol. 17, October 1996
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wave myocardial infarctions reported in the prethrombolytic era (6%-31%y5'171. Several reasons may
explain the relatively low prevalence of non-Q wave
infarction observed in the present study: (1) non-Q wave
myocardial infarctions are more prevalent among recurrent myocardial infarctions'2'181, while this study included patients with a first myocardial infarction only;
(2) in some of the previous studies the diagnosis of
non-Q wave myocardial infarction was based on the
admission electrocardiogram, while in the present study
the diagnosis was based on serial ECG interpretation
during the entire period in hospital. Consequently,
non-Q wave cases on admission were withdrawn from
this category of myocardial infarction if Q waves subsequently developed. In the BHAT study 32% of patients
initially assigned as having 'non-transmural' acute myocardial infarction subsequently developed Q waves'191. In
the Minnesota heart survey, 13-3% of non-Q wave
myocardial infarctions were reclassified as Q-wave myocardial infarctions after repetitive ECG and clinical
assessment were performed'20'. In a recent thrombolytic
study by Matetzky et al., 10% of the Q waves on
admission disappeared during hospitalization and 7%
with non-Q wave on admission subsequently developed
pathological Q waves on the discharge ECG[22'. With
the advent of the reperfusion era, the frequency of
non-Q wave myocardial infarction is increasing steadily;
reperfusion therapies may prevent the development of Q
waves'23'.
1536 S. Behar et al.
infarctions'3'I!U4'251. A follow-up of 36 months of 1446
patients in the placebo arm of BHAT indicated that
patients with a first non-Q wave (n = 263) and those with
a Q wave myocardial infarction (n= 1183) suffered mortality at rates of 7-4% and 8-4% respectively1201. Benhorin
et alP4^ reported similar mortality (non-Q wave, 76%; Q
wave, 6-3%) during an average follow-up period of 25
months of 777 patients randomized to placebo in the
Multicenter Diltiazem Post Infarction Trial. In MILIS,
mortality over 30 months of follow-up was 12% for Q
wave and 13% for non-Q wave myocardial infarctions'171. Berger et a/.'26' reported similar mortality during an observation period of up to 10 years among 363
Framingham Heart Study patients with both types of
myocardial infarction.
Nicod et a/.'8' reported an even higher mortality
rate after hospital discharge in patients with a non-Q
wave (12%) than in patients with a Q wave myocardial
infarction (7%). Increased cardiac mortality following a
first non-Q wave myocardial infarction compared to Q
wave infarction was also reported by Krone et alJ2Si. In
the present study the risk of 10 year death was similar
in both groups of patients with Q and non-Q wave
myocardial infarctions.
In contrast with most previous studies'3'4'7'261, but in
accordance with others'17'24', reinfarction in the year
following the first myocardial infarction occurred
equally among patients with a first Q and a first non-Q
wave myocardial infarction. In other studies the higher
reinfarction rates among non-Q wave myocardial infarction patients was suggested as an explanation for the
similar long-term prognosis of patients with non-Q wave
and Q wave myocardial infarctions'4'20'. The higher
long-term mortality rate in patients with non-Q wave
myocardial infarctions in the present study may also be
due to a higher incidence of fatal reinfarctions in the
former group in comparison to patients with Q wave
infarctions.
Limitations
This study included myocardial infarction patients hospitalized only in coronary care units. It is possible that
myocardial infarction patients with only ST-T changes
on the admission electrocardiogram, considered to be
milder cases of infarction, were hospitalized preferentially in other departments rather than in the coronary
care units and therefore the true incidence of non-Q
wave infarction is underestimated in this study. In
addition, as all patients in this study were admitted in
the early 1980s, no subject was treated with a thrombolytic agent and none of them underwent percutaneous
transluminal coronary angioplasty during the index hospitalization that may have interrupted the development
of Q wave infarction. Systematic coronary angiography
Eur Heart J, Vol. 17, October 1996
Clinical implications
This study is based on a large patient population
hospitalized in 13 different coronary care units with a
first acute myocardial infarction and a mortality
follow-up of up to 10 years. Our results suggest that
patients with non-Q wave myocardial infarctions have a
relatively better prognosis during the acute phase of the
index infarction, associated most probably with smaller
infarction size and less frequent complications during
hospitalization than those with Q wave myocardial
infarctions. However, once the acute phase is over,
myocardial infarction survivors exhibit a prognosis
independent of the presence or absence of Q waves on
the electrocardiogram.
In view of the early occurrence of major cardiac
events in the year following hospital discharge, and the
high mortality rates in the year following discharge,
patients with both first Q and non-Q wave myocardial
infarctions deserve early risk stratification.
The data of this study support the present policy
for management of patients after acute myocardial
infarction, consisting of comprehensive predischarge
evaluation and more aggressive treatment of patients
with non-Q myocardial infarctions.
We are most grateful to Ms Dalia Ben-David for coordinating
the keying and verification of input data, to Mr Mark Goldberg,
for programming the database, to Ms Valentina Boyko for
statistical analysis, to Ms Lynn Goodman for typing the
manuscript, and to Ms Lori Mandelzweig for editorial assistance.
References
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Appendix
SPRINT study group
Executive Board
Henry N. Neufeld, MD Chairman (deceased); Jacob
Agmon, MD Vice-Chairman; Solomon Behar, MD; Uri
Goldbourt, PhD; Henrietta Reicher-Reiss, MD; Edward
Abinader, MD; Jacob Barzilay, MD; Natalio Cristal,
MD; Yaacov Friedman, MD; Nissim Kauli, MD;
Yehezkiel Kishon, MD; Abraham Palant, MD;
Benyamin Peled, MD; Leonardo Reisin, MD; Egon
Riss, MD (deceased); Zwi Schlesinger, MD; Izhar
Zahavi, MD; Monty Zion, MD.
Participating centers, principal investigators, and
physicians
Assaf Harofeh Hospital, Zerifin. Principal investigator:
Zwi Schlesinger, MD. Physician: Moshe Algom, MD.
Barzilai Medical Center, Ashkelon. Principal investigator: Leonardo Reisin, MD. Physician: Newton Yalom,
MD.
Beilinson Medical Center, Petach Tikvah. Principal
investigator: Yaacov Friedman, MD.
Carmel Hospital and Medical Clinic 'Lin' Haifa.
Principal investigator: Abraham Palant, MD. Physician:
Ephraim Mayer, MD.
Central Emek Hospital, Afula. Principal investigator:
Jacob Barzilay, MD. Physician: Lev Bloch, MD.
Hasharon Hospital, Petach Tikvah, Principal investigator: Izhar Zahavi, MD. Physician: Menachem Katz,
MD.
Hillel Yaffe Hospital, Hadera. Principal investigator:
Benyamin Pelled, MD, MSc. Physician: Zakki
Abu-Moukh, MD.
Kaplan Hospital, Rehovot. Principal investigator:
Nissim Kauli, MD. Physician: Emanuel Liebman, MD.
Rambam Medical Center, Haifa. Principal investigator:
Egon Riss, MD, MSc (deceased). Physician: Jamil Hir,
MD.
Bnei Zion Center, Haifa. Principal investigator: Edward
Abinader, MD. Acting Principal investigator: Ehud
Goldhammer, MD. Physician: Salim Maalouf, MD.
Shaare Zedek Medical Center, Jerusalem. Principal
investigator: Monty Zion, MD. Physicians: David
Rosenmann, MD; Jonathan Balkin, MD.
Sheba Medical Center, Tel Hashomer. Principal
investigator: Henrietta Reicher-Reiss, MD.
Wolfson Medical Center, Holon. Principal investigator:
Yehezkiel Kishon, MD. Physician: Ron Narinsky, MD
(deceased).
Coordinating Centre
Solomon Behar, MD. (Director), Uri Goldbourt, PhD
(Epidemiologist), Henrietta Reicher-Reiss, MD (Critical
Events Supervisor), Lori Mandelzweig, MPH.
Eur Heart J, Vol. 17, October 1996
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1537