The Killip Classification for Heart Failure quantifies severity of heart failure in NSTEMI and predicts day mortality. CONCLUSION The Killip and Kimball classification performs relevant prognostic role in mortality at mean follow-up of 05 years post-AMI, with a similar pattern. The Killip classification was based on the evalua- tion of patients . 1 Killip T , Kimball J. Treatment of myocardial infarction in a coronary care unit: a two.
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The classification or index of heart failure severity in patients with acute myocardial infarction AMI was proposed by Killip and Kimball aiming at assessing the risk of in-hospital death and the potential benefit of specific management of care provided in Coronary Care Units CCU during the decade of We evaluated patients with documented AMI and admitted to the CCU, from towith a mean follow-up of 05 years to assess total mortality. Cox proportional regression models were developed to determine the independent association between Killip class and mortality, with sensitivity analyses based on type of AMI.
Kimball 1 in involved bedside stratification. This stratification was claseification on the physical examination of patients with possible acute myocardial infarction AMIand it was used to identify those at the highest risk of death and the potential benefits of specialized care in coronary care units CCUs. There were no objective clinical outcomes nor systematic collection of data or adjustments for confounding factors; moreover, there were no validations in an independent series of patients.
Classificattion cases were stratified into the following classes:.
Although originally described in the pre-reperfusion era, the use of this classification in ST-segment elevation myocardial infarction STEMI was further studied in the post-reperfusion era 23. In contrast, the prognostic value of this classification in non-ST-segment elevation myocardial infarction NSTEMI is not well established, primarily because it has not yet been validated in patients who were not selected from randomized clinical trial databases 4 and considering the paucity of data on late follow-up after AMI.
Therefore, this study aimed to validate the Killip-Kimball classification for total mortality in long-term clinical follow-up and compare its prognostic value in patients with NSTEMI and STEMI in the era of post-reperfusion and modern antithrombotic therapy.
This study comprised two designs 78: Information pertaining to the date of the last evaluation of each living patient, medication used 48 h before the admission and at discharge, and on deaths during hospitalization or long-term clinical follow-up were collected by actively searching the patient’s electronic records, electronic data management systems of the institute, and medical records, as well as via telephone.
We used non-probability sampling considering the paucity of studies that have validated the Killip-Kimball classifiation to estimate the risk of mortality in patients with AMI in the Brazilian population. It is notable that our sample size was considerably greater than that in the study, which included patients with a suspected diagnosis of AMI.
The study excluded patients with unstable angina. The criteria used for AMI diagnosis was based on the recommendations of the guidelines avaliable between and This condition was confirmed by increased levels of myocardial necrosis biomarkers at the time of AMI between andi. When the ECG showed ST-segment depression, T-wave inversion, or nonspecific findings in serial tracings along with the increased levels of myocardial necrosis cladsification, AMI diagnosis without persistent ST-segment elevation was confirmed.
In this study, we analyzed demographic variables age, gender, and ethnicitycardiovascular risk factors and comorbidities, physical examination information for the Killip-Kimball classification, simple hemodynamic parameters heart rate and systolic and diastolic blood pressureprevious treatments and procedures, and angiographic aspects [affected artery, TIMI flow, extent and severity of coronary artery disease CAD in those undergoing coronary angiography].
We defined total mortality as the clinical outcome of interest, with landmark analysis at day 30 and at the end of the follow-up period. The distributions of discrete or categorical variables are expressed as frequencies and percentages, and comparisons were calculated using chi-square or Fisher’s exact test. Analysis of the clinical outcome was based on the time to occurrence of death, according to the cumulative Kaplan-Meier survival curves and depending on the Killip class.
Univariate Cox regression analysis included all demographic, clinical, and angiographic variables. The backward stepwise procedure enabled clssification identification of the independent variables for the risk of death, according to AMI type. The main general characteristics of patients with AMI are described below as well as shown in Table 1according to the Killip kiillip. Overall, the median age IQR was 64 As for the ECG, 4. Coronary artery bypass graft; AMI: Patients were followed since hospital admission during treatment at the CCU and until the last evaluation in the institution to determine their vital status or until death, if applicable.
Killip Classification for Heart Failure – MDCalc
The maximum follow-up time was days; the average follow-up time was five years, achieved in The primary outcome of total mortality was observed in patients i. The frequencies of death, according to the Killip class, in total long-term clinical follow-up were as follows: Killip class I, The same was observed in the period up to 30 days Figure 1.
With ST-segment elevation MI. The risk models included clinical characteristics such as age, gender, cardiovascular risk factors, physical examination and hemodynamic findings, history, treatments and procedures performed previously and during hospitalization, Killip-Kimball classification, and AMI type.
The variables that showed significant association with mortality were selected. Four models were constructed to explore the association between the Killip class, AMI type, and risk of death using clinical variables on admission and in-hospital Tables Consistently, the Killip-Kimball classification was an independent predictor of increased risk of mortality.
Cox model with initial data on hospital admission and predictors of mortality in the total follow-up of patients with STEMI.
Coronary artery bypass graft; SE: Cox model with initial data on hospital admission and predictors of mortality in the total follow-up of patients with NSTEMI. Cox model with in-hospital data and predictors of mortality in the total follow-up of patients with STEMI. To date and to the best of our knowledge, this study introduces three important aspects: We emphasize that in this study, the Killip classification was an important independent predictor of mortality, even after adjustment for important covariates such as clinical, laboratory, electrocardiographic, and angiographic characteristics related with the risk of mortality in patients with AMI, as well as of the occurrence of relevant complications independently associated with the risk of death, including cardiac arrest during hospitalization and acute renal failure 9 Moreover, this analysis highlights the clinical utility of physical examination as a simple tool easy to apply and without any sophisticated technological requirements to identify signs and symptoms of HF on admission.
In all Cox proportional hazards models, the variables independently associated with the risk of mortality were consistently maintained at the end of the stepwise procedure, particularly age, emphasizing that the Killip classification is a robust predictor of mortality.
We detected a direct, significant, and independent association between the Killip classification and risk of death during late follow-up post-AMI. In fact, there was consistent risk stratification at day, 5-year, and total follow-up time post-AMI.
Mortality was assessed at 30 days and at 6 months.
They identified an independent association with total mortality during these time periods; however, they used only the variables on admission; they did not adjust for iillip treatments, and the data were derived from those included in randomized clinical trials. Classsification study, in contrast, has some important differences.
We included patients recruited from daily clinical practice; they were not randomized; therefore, they had characteristics with higher severity, such as more comorbidities and older age, implying a higher representativeness and applicability to “real world” settings.
In contrast to a previous study 15our Cox models were adjusted for the use of pharmacological therapies and in-hospital procedures, with noticeable impact on survival.
This potential interaction was evaluated in the models, and despite the possible attenuation of the association with risk for the reason described earlier, the Killip classification significantly and independently remained associated with mortality. The distribution pattern of the survival curves at day and long-term follow-up, according to the Killip class, probably reflected the high intrinsic risk of acute coronary event, particularly in those who developed cardiogenic shock, mainly in the STEMI group, with distinct separation between the curves.
We emphasize that the proportionately smaller numbers of patients with poor prognosis in these classes did not allow the determination of whether the behavior is similar or different from a visual perspective only. We also emphasize the pronounced decrease in survival in the first days after AMI for the highest Killip classes.
Furthermore, it is notable that the differences in survival distributions at day and long-term follow-up were statistically significant; this observation was similar for the two AMI groups. Moreover, as the cumulative number of deaths increases with long-term follow-up, the Kaplan-Meier survival curves reflect the distributions according to the risk inherent to the Killip class. Patients in Killip class I have an excellent prognosis, both in short- and long-term, whereas those in class III or IV have larger areas of necrosis, left ventricular remodeling and systolic dysfunction, and probably a greater extent of CAD.
Thus, STEMI patients with higher HF severity classes survived the initial stage possibly because the AMI-related artery was treated using an artery reperfusion strategy; moreover, they may have been at a lower risk of new events due to CAD, mostly unilateral, or at a younger age. On the other hand, NSTEMI patients with more extensive CAD, probably older, and having survived the initial stage may have been more susceptible to new, recurrent thrombotic events, including AMI and ischemic cardiomyopathy; this may explain the increased risk of death in this group.
In terms of biological plausibility and emphasizing the negative impact on survival, the associations of the Killip-Kimball classification with increased risk of death were consistent with physical examination variables. These are representative of the hemodynamic status of patients on admission, i.
In fact, the Killip-Kimball classification maintained a significant association with the risk of death even after adjusting for these variables, with biological and statistical impact. The mortality rates at 6 months in the study by Khot et al 4 were as follows: We emphasize that these data refer only to the NSTEMI population, which was analyzed by the authors, and only for 6 months of follow-up.
Comparing this data with our data Killip class I, There were some limitations of this study.
Killip class – Wikipedia
Moreover, as the Killip-Kimball classification criteria were designed to be easily implemented and the datasheets of the patients were reviewed for consistency even with some disagreementthe association with risk would have been reduced or nulled and the hypothesis would not have been confirmed, which was not the case. Another aspect is the non-comparison with other diagnostic tests for left ventricular dysfunction, such as transthoracic echocardiography, in order to determine left ventricular ejection fraction and measurement clasification the natriuretic peptide NT-pro-BNP.
However, from the perspective of clinical applicability and generalization of the results, the use of these additional tests would result in additional costs and logistical difficulties to the objectives and hypotheses of this research. Other limitations, as in other observational studies, could include possible selection biases and not elucidating confounding factors, resulting in a non-ideal fit in the Cox proportional hazards models.
Moreover, in terms of scientific and clinical relevance, this study adds evidence to the available information on the Killip-Kimball classification in terms of prognostic value for mortality in very late follow-up post-AMI.
The Killip-Kimball classification demonstrates a discriminatory capacity of the risk of total mortality, even after adjusting for clinical covariates that are relevant in the contemporary era. Potential Conflict of Interest. No potential conflict of interest relevant to this iimball was reported. National Center for Biotechnology InformationU. Journal List Arq Bras Cardiol v. Author information Article notes Copyright and License information Disclaimer. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Abstract Background The classification or index of heart failure severity in patients with acute myocardial infarction AMI was proposed by Killip and Kimball aiming at assessing the risk of in-hospital death and the potential benefit of specific management of care provided in Coronary Care Units CCU during the decade of Methods We evaluated patients with documented AMI and admitted to the CCU, from towith a mean follow-up of 05 years to assess total mortality.
The cases classificaton stratified into the following classes: Method Study Design This study comprised two designs 78: Data collection Information pertaining to the date of the last evaluation of each living patient, medication used 48 h before the admission and at discharge, and on deaths during hospitalization clasification long-term clinical follow-up were collected by actively searching the patient’s electronic records, electronic data management systems of the institute, and medical records, as well as via telephone.
Sampling We used non-probability sampling considering the paucity of studies that have validated the Killip-Kimball classification to estimate the risk of mortality in patients with AMI in the Brazilian population. Results Patient characteristics The main general characteristics of patients with AMI are described below as well as shown in Table 1according to the Killip class. mimball
Table 1 Clinical characteristics according to the Killip—Kimball. Open in a separate window. Clinical follow-up and total mortality Patients were followed since hospital admission during treatment at the CCU and until the last evaluation in the institution to determine their vital status or until death, if applicable.
Cox proportional hazards model The risk models included clinical characteristics such as age, gender, cardiovascular risk factors, physical examination and hemodynamic findings, history, treatments and procedures performed previously and during hospitalization, Killip-Kimball classification, and AMI type. Table 2 Cox model with initial data on hospital admission and predictors of mortality in the total follow-up of patients with STEMI. B SE Wald p. Footnotes Author contributions Conception and design of the research: Oliveira GBF; Acquisition of data: Killip 3rd T, Classificatiln JT.