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J Am Coll Cardiol, 1998; 32:596-605 © 1998 by the American College of Cardiology Foundation |
* Henry Ford Health System, Henry Ford Heart and Vascular Institute, Detroit, Michigan, USA
William Beaumont Hospital, Royal Oak, Michigan, USA
Botsford Hospital, Farmington Hills, Michigan, USA
Riverside Hospital, Trenton, Michigan, USA
|| Providence Hospital, Southfield, Michigan, USA
Manuscript received April 10, 1998; revised manuscript received May 4, 1998, accepted May 15, 1998.
Address for correspondence: Dr. Peter A. McCullough, Cardiovascular Division, Henry Ford Hospital, Henry Ford Health System, Center for Clinical Effectiveness, One Ford Place, Suite 3C, Detroit, Michigan 48202 or; worldwide web: http://www.hfhs-cce.org/
pmc{at}mich.com
pmccull1{at}smtpgw.is.hfh.edu
Objectives. The purpose of this study was to determine if early triage angiography with revascularization, if indicated, favorably affects clinical outcomes in patients with suspected acute myocardial infarction who are ineligible for thrombolysis.
Background. The majority of patients with acute myocardial infarction and other acute coronary syndromes are considered ineligible for thrombolysis and therefore are not afforded the opportunity for early reperfusion.
Methods. This multicenter, prospective, randomized trial evaluated in a controlled fashion the outcomes following triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Eligible patients (n = 201) with <24 h of symptoms were randomized to early triage angiography and subsequent therapies based on the angiogram versus conventional medical therapy consisting of aspirin, intravenous heparin, nitroglycerin, beta-blockers, and analgesics.
Results. In the triage angiography group, 109 patients underwent early angiography and 64 (58%) received revascularization, whereas in the conservative group, 54 (60%) subsequently underwent nonprotocol angiography in response to recurrent ischemia and 33 (37%) received revascularization (p = 0.004). The mean time to revascularization was 27 ± 32 versus 88 ± 98 h (p = 0.0001) and the primary endpoint of recurrent ischemic events or death occurred in 14 (13%) versus 31 (34%) of the triage angiography and conservative groups, respectively (45% risk reduction, 95% CI 27–59%, p = 0.0002). There were no differences between the groups with respect to initial hospital costs or length of stay. Long-term follow-up at a median of 21 months revealed no significant differences in the endpoints of late revascularization, recurrent myocardial infarction, or all-cause mortality.
Conclusions. Early triage angiography in patients with acute coronary syndromes who are not eligible for thrombolytics reduced the composite of recurrent ischemic events or death and shortened the time to definitive revascularization during the index hospitalization. Despite more frequent early revascularization after triage angiography, we found no long-term benefit in cardiac outcomes compared with conservative medical therapy with revascularization prompted by recurrent ischemia.
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