CLINICAL STUDIES
Early angiography versus conservative treatment in patients with non–ST elevation acute myocardial infarction
Grant S. Scull, MD*,
Jenny S. Martin, RN*,
W. Douglas Weaver, MD, FACC ,
Nathan R. Every, MD, MPH for the MITI Investigators
* Division of Cardiology, University of Washington, Seattle, Washington, USA
the Heart and Vascular Institute, Henry Ford Health System, Detroit, Michigan, USA
the Northwest Health Services Research and Development Center of Excellence, VA Puget Sound Healthcare System, Seattle, Washington, USA
Manuscript received November 2, 1998;
revised manuscript received September 10, 1999,
accepted December 2, 1999.
Reprint requests and correspondence: Dr. Nathan R. Every, COR Center, 1910 Fairview Avenue East, #205, Seattle, Washington 98102
nevery{at}u.washington.edu
OBJECTIVES
To compare short- and long-term outcome after early invasive or conservative strategies in the treatment of non-ST segment elevation acute myocardial infarction (AMI).
BACKGROUND
It is uncertain whether or not there is benefit from emergent invasive diagnosis and treatment of AMI in patients without ST segment elevation on the admission electrocardiogram (ECG).
METHODS
In a cohort of 1,635 consecutive patients with AMI who presented to hospitals without ST segment elevation on their admission ECG, we compared treatments, hospital course and outcome in 308 patients who presented to hospitals whose initial strategy favored early angiography and appropriate intervention when indicated versus 1,327 similar patients who presented to hospitals that favor a more conservative initial approach.
RESULTS
At baseline, patients admitted to hospitals favoring an early invasive strategy were younger, more predominately Caucasian and had less comorbidity. Early coronary angiography occurred in 58.8% versus 8% (p < 0.001), and early angioplasty was performed in 44.8% versus 6.1% (p < 0.001) in the two different cohorts. Patients treated in hospitals favoring the early invasive strategy had a lower 30-day (5.5% vs. 9.5%, p = 0.026) and four-year mortality (20% vs. 37%, p < 0.001). Multivariate analysis showed a trend towards lower hospital mortality (OR = 0.56, 95% CI: 0.29 to 1.09) and a significant lower long-term mortality (hazard ratio = 0.61, 95% CI: 0.47 to 0.80) in patients admitted to hospitals favoring an early invasive strategy.
CONCLUSIONS
These data suggested that an early invasive strategy in patients with AMI and nondiagnostic ECG changes is associated with lower long-term mortality.
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Abbreviations and Acronyms
| | ACEI | = angiotensin converting enzyme inhibitor | | AMI | = acute myocardial infarction | | CHARS | = Washington State Comprehensive Hospital Abstract Reporting System | | ECG | = electrocardiogram | | MITI | = Myocardial Infarction Triage and Intervention | | SES | = socioeconomic status | | TIMI | = Thrombolysis in Myocardial Infarction | | VANQWISH | = Veterans Affairs Non-Q Wave Infarction Strategies in Hospital |
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