Identifying patients with refusal of percutaneous coronary intervention for acute myocardial infarction: a classification and regression tree analysis

  • Manyan Wu
  • Long Li
  • Sufang Li
  • Yuxia Cui
  • Dan Hu
  • Junxian Song
  • Chongyou Lee
  • Hong ChenEmail author


The purpose of the present study is to develop and validate a prediction tool to identify patients who refuse to receive percutaneous coronary intervention (PCI) rapidly. We developed a risk stratification model using the derivation cohort of 288 patients with ST segment elevation myocardial infarction (STEMI) in our hospital and validated it in a prospective cohort of 115 patients. There were 52 (18.1%) patients and 18 (15.7%) patients who refused PCI among derivation and validation cohort, respectively. A classification and regression tree (CART) analysis and multivariate logistic regression were used for statistical analysis. The decision-making factors for refusal of PCI were also investigated. The CART analysis and logistic regression both showed that self-rated mild symptom was the most significant predictor of not choosing PCI. The model generated three risk groups. The high-risk group included: self-rated mild symptoms; self-rated severe symptom, glomerular filtration rate < 60 ml/min/1.73m2. The intermediate-risk group included: self-rated severe symptom, glomerular filtration rate ≥ 60 ml/min/1.73m2 and age ≥ 75 years. The low-risk group included: self-rated severe symptom, glomerular filtration rate ≥ 60 ml/min/1.73m2 and age < 75 years. The prevalence for refusal of PCI of the three groups were 45%–44%, 18% and 4%, respectively. The sensitivity was 88% and the negative predictive value was 96%. And similar results were obtained when this prediction tool was applied prospectively to the validation cohort. Patients at low and high risk can be easily identified for refusal of PCI by the prediction tool using common clinical data. This practical model might provide useful information for rapid recognition and early response for this kind of crowd.


Acute myocardial infarction Percutaneous coronary intervention Clinical prediction rule 



This study was supported by National Natural Science Foundation of China (81770356).

Conflict of interest

There were no potential conflicts of interest in this study, including related consultancies, shareholdings and grant funding.

Statement of human and animal rights

Our study has been approved by the institutional research ethics committee of our hospital (2014PHB125-01) and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki.

Informed consent

Informed consent was obtained from each patient.

Supplementary material

11739_2019_2079_MOESM1_ESM.pdf (295 kb)
Supplementary file1 (PDF 295 kb)


  1. 1.
    GBD (2017) Causes of Death Collaborators (2018) Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392:1736–1788Google Scholar
  2. 2.
    Benjamin EJ, Muntner P, Alonso A et al (2019) Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 139:e56–e66CrossRefPubMedGoogle Scholar
  3. 3.
    Nguyen AV, Thanh LV, Kamel MG et al (2017) Optimal percutaneous coronary intervention in patients with ST-elevation myocardial infarction and multivessel disease: An updated, large-scale systematic review and meta-analysis. Int J Cardiol 244:67–76CrossRefPubMedGoogle Scholar
  4. 4.
    O'Gara PT, Kushner FG, Ascheim DD et al (2013) 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 127:529–555CrossRefPubMedGoogle Scholar
  5. 5.
    Ibanez B, James S, Agewall S et al (2017) 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 39:119–177CrossRefGoogle Scholar
  6. 6.
    Windecker S, Kolh P, Alfonso F et al (2015) 2014 ESC/EACTS guidelines on myocardial revascularization. Euro Intervention 10:1024–1094PubMedGoogle Scholar
  7. 7.
    Li J, Li X, Wang Q et al (2015) ST-segment elevation myocardial infarction in China from 2001 to 2011 (the China PEACE-Retrospective Acute Myocardial Infarction Study): a retrospective analysis of hospital data. Lancet 385:441–451CrossRefPubMedGoogle Scholar
  8. 8.
    Xun YW, Yang JG, Song L et al (2010) In-hospital delay to primary angioplasty for patients with ST-elevated myocardial infarction between cardiac specialized hospitals and non-specialized hospitals in Beijing, China. Chin Med J (Engl) 123:800–805Google Scholar
  9. 9.
    Zhou S, Chen J, Xu RY et al (2014) Factors associated with the use of percutaneous coronary intervention in elderly Chinese patients with a first ST elevated acute myocardial infarction. Patient Prefer Adherence 8:257–262PubMedGoogle Scholar
  10. 10.
    Altamirano J, Lopez-Pelayo H, Michelena J et al (2017) Alcohol abstinence in patients surviving an episode of alcoholic hepatitis: Prediction and impact on long-term survival. Hepatology 66:1842–1853CrossRefPubMedGoogle Scholar
  11. 11.
    Odaka Y, Takahashi J, Tsuburaya R et al (2017) Plasma concentration of serotonin is a novel biomarker for coronary microvascular dysfunction in patients with suspected angina and unobstructive coronary arteries. Eur Heart J 38:489–496PubMedGoogle Scholar
  12. 12.
    Kattan MW (2010) Classification and regression trees versus nomograms: a bone scan positivity example. Eur Urol 57:559–561CrossRefPubMedGoogle Scholar
  13. 13.
    Lehmann G, Schmitt C, Kehl V et al (2003) Electrocardiographic algorithm for assignment of occluded vessel in acute myocardial infarction. Int J Cardiol 89:79–85CrossRefPubMedGoogle Scholar
  14. 14.
    Hochholzer W, Trenk D, Fromm MF et al (2010) Impact of cytochrome P450 2C19 loss-of-function polymorphism and of major demographic characteristics on residual platelet function after loading and maintenance treatment with clopidogrel in patients undergoing elective coronary stent placement. J Am Coll Cardiol 55:2427–2434CrossRefPubMedGoogle Scholar
  15. 15.
    Thygesen K, Alpert JS, Jaffe AS et al (2012) Third universal definition of myocardial infarction. Circulation 126:2020–2035CrossRefPubMedGoogle Scholar
  16. 16.
    Bahreini M, Jalili M, Moradi-Lakeh M (2015) A comparison of three self-report pain scales in adults with acute pain. J Emerg Med 48:10–18CrossRefPubMedGoogle Scholar
  17. 17.
    Rothberg MB, Sivalingam SK, Kleppel R et al (2015) Informed Decision Making for Percutaneous Coronary Intervention for Stable Coronary Disease. JAMA Intern Med 175:1199–1206CrossRefPubMedGoogle Scholar
  18. 18.
    Song JX, Zhu L, Lee CY, Ren H et al (2016) Total ischemic time and outcomes for patients with ST-elevation myocardial infarction: does time of admission make a difference? J Geriatr Cardiol 13:658–664PubMedGoogle Scholar
  19. 19.
    Fazel R, Krumholz HM, Bates ER et al (2009) Choice of reperfusion strategy at hospitals with primary percutaneous coronary intervention: a National Registry of Myocardial Infarction analysis. Circulation 120:2455–2461CrossRefPubMedGoogle Scholar
  20. 20.
    Zhang SY, Hu DY, Sun YH et al (2008) Current management of patients with ST elevation myocardial infarction in Metropolitan Beijing, China. Clin Invest Med 31:E189–E197CrossRefPubMedGoogle Scholar
  21. 21.
    Gao R, Patel A, Gao W et al (2008) Prospective observational study of acute coronary syndromes in China: practice patterns and outcomes. Heart 94:554–560CrossRefPubMedGoogle Scholar
  22. 22.
    Schiele F, Hochadel M, Tubaro M et al (2010) Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction. Eur Heart J 31:2614–2624CrossRefPubMedGoogle Scholar
  23. 23.
    de Boer SP, Barnes EH, Westerhout CM et al (2011) High-risk patients with ST-elevation myocardial infarction derive greatest absolute benefit from primary percutaneous coronary intervention: results from the Primary Coronary Angioplasty Trialist versus thrombolysis (PCAT)-2 collaboration. Am Heart J 161:500–507CrossRefPubMedGoogle Scholar
  24. 24.
    Keeley EC, Boura JA, Grines CL (2003) Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 361:13–20CrossRefPubMedGoogle Scholar
  25. 25.
    Stone GW (2008) Angioplasty strategies in ST-segment-elevation myocardial infarction: part I: primary percutaneous coronary intervention. Circulation 118:538–551CrossRefPubMedGoogle Scholar
  26. 26.
    Dong S, Chu Y, Zhang H et al (2014) Reperfusion times of ST-Segment elevation myocardial infarction in hospitals. Pak J Med Sci 30:1367–1371CrossRefPubMedGoogle Scholar
  27. 27.
    Eagle KA, Goodman SG, Avezum A et al (2002) Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). Lancet 359:373–377CrossRefPubMedGoogle Scholar
  28. 28.
    Avezum A, Makdisse M, Spencer F et al (2005) Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J 149:67–73CrossRefPubMedGoogle Scholar
  29. 29.
    Gharacholou SM, Alexander KP, Chen AY et al (2010) Implications and reasons for the lack of use of reperfusion therapy in patients with ST-segment elevation myocardial infarction: findings from the CRUSADE initiative. Am Heart J 159:757–763CrossRefPubMedGoogle Scholar
  30. 30.
    Hall M, Laut K, Dondo TB et al (2014) Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003–2013. Heart 102:313–319CrossRefGoogle Scholar
  31. 31.
    Ranasinghe I, Rong Y, Du X et al (2014) System barriers to the evidence-based care of acute coronary syndrome patients in China: qualitative analysis. Circ Cardiovasc Qual Outcomes 7:209–216CrossRefPubMedGoogle Scholar
  32. 32.
    Hochman JS, Sleeper LA, White HD et al (2001) One-year survival following early revascularization for cardiogenic shock. JAMA 285:190–192CrossRefPubMedGoogle Scholar

Copyright information

© Società Italiana di Medicina Interna (SIMI) 2019

Authors and Affiliations

  1. 1.Department of Cardiology, Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Center for Cardiovascular Translational ResearchPeking University People’s HospitalBeijingChina

Personalised recommendations