Original Contribution
Killip classification in patients with acute coronary syndrome: insight from a multicenter registry

https://doi.org/10.1016/j.ajem.2010.10.011Get rights and content

Abstract

The purpose of this study was to assess the prognostic value of the Killip classification at the presentation in patients with acute coronary syndrome (ACS). In 2007 and over 5 months, 6704 consecutive patients with ACS were enrolled in the Gulf Registry of Acute Coronary Events. Patients were categorized according to Killip classification at presentation (Classes I, II, III, and IV). Patients' characteristics and in-hospital outcomes were analyzed. High Killip classes were defined in 22% of patients. In comparison to Killip Class I, patients with higher Killip class had greater prevalence of cardiovascular risk factors, presented late, were less likely to have angina, and were less likely to receive antiplatelet, statins, and β-blockers. Classes II, III, and IV were associated with higher adjusted odds of death in ST-elevation myocardial infarction (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.25–3.69; OR 6.1, 95% CI 3.41–10.86; and OR 28, 95% CI 15.24–54.70, respectively) and non–ST-elevation acute coronary syndrome (adjusted OR 2.4, 95% CI 1.24–4.82; OR 3.2,95% 1.49–7.02; and OR 9.8, 95% CI 3.79–25.57, respectively). In conclusion, across ACS, patients with higher Killip class had worse clinical profile and were less likely to be treated with evidence-based therapy. High Killip class was independent predictors of mortality in ST-elevation myocardial infarction and non–ST-elevation acute coronary syndrome. Physician in the emergency department should be aware of the importance of clinical examination in the risk stratification in patients presenting with ACS.

Introduction

Killip classification is a simple clinical tool that has been previously studied in patients with ST-elevation myocardial infarction (STEMI) [1], [2], [3]. According to Killip and Kimball criteria, patients were classified into 4 classes during physical examination. Patients in Class I demonstrated no evidence of heart failure (HF). Patients in Class II had findings consistent with mild to moderate HF; patients in Class III demonstrated overt pulmonary edema and patients in Class IV were in cardiogenic shock [2]. Post-MI risk stratification that has been derived from several clinical trials is important to set the appropriate treatment and prognosis. Patients with higher Killip class were found to have more severe angiographic coronary artery disease, higher incidence of ventricular dysfunction, and larger myocardial infarctions [2], [3]. However, similar data from patients with non–ST-elevation acute coronary syndrome (NSTEACS) are limited. Awareness of patients' Killip class at the presentation is a crucial step in the risk stratification strategy. Herein, we assess the incidence and prognostic value of Killip classification at the presentation in different types of the ACS spectrum.

Section snippets

Methods

Data are derived from a prospective, observational, multinational, multicenter study of the Gulf Registry of Acute Coronary Events (Gulf RACE). In 2007 and for 5 months, Gulf RACE recruited 6704 consecutive ACS patients from 64 hospitals in 6 Middle Eastern countries (Bahrain, Kuwait, Qatar, Oman, United Arab Emirates, and Yemen). The study received ethical approval from the institutional ethical bodies in all participating countries. The rationale and details of Gulf RACE have been described

Results

Killip classes (I, II, III, and IV) were successfully defined in 6689 patients. Patients with high Killip class (II = 13%, III = 7%, and IV = 2%) were older and had a greater prevalence of previous coronary artery disease, diabetes, hypertension, dyslipidemia, and renal impairment in comparison to Killip Class I. Table 1, Table 2 summaries baseline characteristics of patients presenting with ACS in different Killip classes. Patients with STEMI and NSTEACS had almost similar baseline

Discussion

The current study evaluated the incidence and prognosis of the on-admission Killip classification in patients presenting with ACS. The key findings of this study were the following: (1) Killip Class II, III, and IV patients had higher risk profiles and rates of major adverse clinical events across ACS. (2) Despite their higher inherent risk, patients with higher Killip class continued to receive less coronary angiography and less evidence-based therapies compared with their counterparts in

References (16)

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Funding: Gulf Registry of Acute Coronary Events (Gulf RACE) is a Gulf Heart Association project and was financially supported by Sanofi Aventis, Paris, and Qatar Telecommunications Company, Doha, Qatar. The sponsors had no role in study design, data collection, data analysis, writing of the report or submission of the manuscript.

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