Naslov
40 years since Killip classification

Autori
Ivanuša, Mario ; Miličić, Davor

Izvornik
International journal of cardiology (0167-5273) 134 (2009), 3; 420-421

Vrsta, podvrsta i kategorija rada
Radovi u časopisima, članak, stručni

Sažetak
Although during the last decades the definition, treatment and in-hospital mortality of acute myocardial infarction (AMI) has significantly changed, an adequate history and clinical examination, as well as monitoring of electrocardiographic changes still have non-replaceable role in the risk stratification of patients with AMI. More than 60 years ago it has been described that some factors with AMI patients cause greater in-hospital mortality. The patients were then classified into mild and severe AMI groups. The group of patients with severe AMI included the patients of older age, higher sedimentation rate, leucocytosis followed by a higher temperature, previous myocardial infarction, cardiogenic shock or left ventricular dysfunction. The first quantitative severity AMI index (Pathologic Index Rating) was described by Schnur in 1953. The variables at the time of admittance (a presence of cardiogenic shock, heart failure, presence of gallop rhythm, rhythm disorders, comorbidity and history of previous cardiovascular diseases) were also rated according to their sum and the patients were rated according to clinical manifestations into categories of mild, moderate, moderate to severe, severe and critically severe AMI. Every rate was estimated a short-term mortality evaluated at 8% in cases of mild disease to 95% in critically severe clinical manifestations. In 1962 Peel et al. published AMI severity index used for the purpose of anticipating of the outcome in the first 28 days. Using history of previous cardiovascular diseases, the demographic characteristics (age and gender), clinical manifestations (heart failure, cardiogenic shock) and electrocardigraphic changes (changes in QRS-complex and T-waves, presence of branch block and rhythm disorders) the result of the Coronary Prognostic Index was shown from 1 to 28 using numerical system. Every index result was assigned a certain short-term mortality, so that a greater number designate a greater frequency of a deadly outcome in the first 28 days of AMI. After Killip and Kimball had published their article in the American Journal of Cardiology in October 1967 nobody could anticipate that a detailed description of a 2 year experience of treatment of AMI in the Coronary Care Unit of New York Hospital-Cornell Medical Center would be such an important contribution to the clinical cardiology of the XX and XXI century. The information on the Science Citation Index is an indication of 315 citations during the period from 1967 to 1982, and after having searched the Web of Science for the period from 1967 to 3rd November 2007 there were 1094 citations of this article that we include in the cardiology classics. The fundamental question was whether the treatment in coronary care unit (CCU) saves patients' lives suffering from AMI. The authors answered on that question by using the data analysis of 250 patients admitted consecutively to the CCU with proved AMI forming a clinical severity classification. The distribution of the patients proved in their study that 33% patients of the class I had no heart failure, 38% of the class II had heart failure, 10% of the class III had severe heart failure and 19% patients of the class IV suffered from cardiogenic shock. Average age, frequency of lethal arrhythmia and cardiac arrest, and in-hospital mortality (from 6%, 17%, 38% and 81% for the patients of the classes I– IV or on average for all patients 32%) has increased accordingly with the clinically estimated severity of left ventricular dysfunction. Although some subsequent studies as a result of the application of the modern pharmacoinvasive therapy have proved a lowered total mortality of patients suffering from AMI, this classification has remained a powerful predictor of an outcome in the short and long term for the period before the use of reperfusion treatment, at the time of fibrinolytic therapy and at the time of a modern intervention treatment. A simple ranking is very cheap at the same time since it requires nothing more than common bedside procedures (history and clinical examination) and can be applied at the time of admittance and also later during the treatment. The advantages of the classification are independence of demographic characteristics, laboratory results, comorbidity, localization and type of AMI. An inadequately precise definition of the II and III classes, due to clinical diagnosis of heart failure is a shortcoming of this index. Although the chest X-ray may determine signs of left ventricular dysfunction within the majority of patients and may help in risk stratification, others with normal chest X-ray have signs of hemodynamic cardiogenic disorder. The results obtained by Bergstra et al. have determined that a large proportion of acute ST-elevation myocardial infarction (STEMI) patients without clinical signs of heart failure have moderate or even severe elevation of right- as well as left-sided cardiac filling pressures. Henriques et al. have found out that Killip class and age, and procedural success or failure in patients treated with primary angioplasty for STEMI, may be a good predictor of 30-day mortality. It is not easy to answer how even after 40 years of Killip classification is possible to upgrade this index? We believe that a routine use of Killip classification and age could ensure simple and efficient risk stratification at the time of admittance of patients with AMI.

Izvorni jezik
Engleski

Znanstvena područja
Kliničke medicinske znanosti

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