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CLINICAL STUDY: MYOCARDIAL INFARCTION

Non–Q-wave myocardial infarction following thrombolytic therapy: a comparison of outcomes in patients randomized to invasive or conservative post-infarct assessment strategies in the Veterans Affairs Non–Q-Wave Infarction Strategies In-Hospital (VANQWISH) trial

Laura F. Wexler, MD, FACC^*, Alvin S. Blaustein, MD, Philip W. Lavori, PhD, Kenneth G. Lehmann, MD, Michael Wade, MS^||, William E. Boden, MD^{|| **} for the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators^¶

^* Veterans Affairs Medical Center and the University of Cincinnati, Cincinnati, Ohio, USA
Veterans Affairs Medical Center, Houston, Texas, USA
Department of Veterans Affairs Cooperative Studies Program Coordinating Center, Palo Alto, California, USA
Veterans Affairs Medical Center, Seattle, Washington, USA
^|| State University of New York Health Science Center, Syracuse, New York, USA
^** Hartford Hospital, Hartford, Connecticut, USA

Manuscript received January 19, 2000; revised manuscript received July 24, 2000, accepted September 13, 2000.

Reprint requests and correspondence: Dr. Laura F. Wexler, Cardiology Section, Department of Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, Ohio 45220
Wexlerl{at}ucmail.uc.edu

OBJECTIVES

We wished to determine the effect of post-infarct management strategy on event rates (death or recurrent nonfatal myocardial infarction [MI]) in patients who evolved non–Q-wave MI (NQMI) following thrombolytic therapy.

BACKGROUND

Patients who evolve NQMI following thrombolytic therapy are often considered to be at high risk and are frequently managed with routine early invasive testing despite a lack of data supporting improved outcome.

METHODS

The Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital (VANQWISH) study included 115 patients who evolved NQMI following thrombolytic therapy. We compared the event rates in patients randomized to routine early coronary angiography with those in patients randomized to a conservative strategy of noninvasive functional assessment, with angiography reserved for patients with spontaneous or induced ischemia.

RESULTS

During an average follow-up of 23 months, 19 of 58 patients (33%) randomized to the invasive management strategy died or suffered recurrent nonfatal MI, compared with 11 of 57 patients (19%) randomized to the conservative strategy (p = 0.152). Equivalent numbers of patients were subjected to revascularization (percutaneous transluminal coronary angioplasty or coronary artery bypass graft). There were more deaths in the invasive management group than in the conservative management group (11 vs. 2). Excess deaths could not be attributed to periprocedural mortality.

CONCLUSIONS

Overall event rates (death or recurrent nonfatal MI) are comparable with conservative and invasive strategies in patients who evolve NQMI following thrombolytic therapy. Mortality rate in patients managed conservatively is low (3.5%), and routine invasive management may be associated with an increased risk of death.

Abbreviations and Acronyms   CABG = coronary artery bypass graft   CON = conservative management strategy   INV = invasive management strategy   LVEF = left ventricular ejection fraction   MI = myocardial infarction   NQMI = non-Q wave myocardial infarction   PTCA = percutaneous transluminal coronary angioplasty   TIMI = Thrombolysis In Myocardial Infarction   VANQWISH = Veterans Affairs Non–Q-Wave Infarction Strategy In-Hospital

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