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CLINICAL STUDY: NON-Q-WAVE MYOCARDIAL INFARCTION

Stress test criteria used in the conservative arm of the frisc-ii trial underdetects surgical coronary artery disease whenapplied to patients in the vanqwish trial

Abhinav Goyal, MD^*, Frederick F. Samaha, MD, FACC, William E. Boden, MD, FACC, Michael J. Wade, MS^|| and Stephen E. Kimmel, MD, MS, FACC^¶,*

^* University of Pennsylvania School of Medicine, Department of Medicine, Philadelphia, Pennsylvania, USA
Cardiovascular Division, Philadelphia, Pennsylvania, USA
Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
Hartford Hospital, Hartford, Connecticut, USA
^|| Veterans Affairs Medical Center, Syracuse, New York, USA
^¶ Center for Clinical Epidemiology and Biostatistics, Philadelphia, Pennsylvania, USA

Manuscript received October 10, 2001; revised manuscript received February 19, 2002, accepted February 25, 2002.

^* Reprint requests and correspondence: Dr. Stephen E. Kimmel, University of Pennsylvania School of Medicine, Center for Clinical Epidemiology and Biostatistics, 717 Blockley Hall, 423 Guardian Drive, Philadelphia, Pennsylvania 19104-6021.
skimmel{at}cceb.med.upenn.edu

OBJECTIVES: We sought to determine whether the stringent stress test criteria for crossover to cardiac catheterization in the conservative arm of the Fast Revascularization During Instability in Coronary Artery Disease (FRISC-II) trial subjected this strategy to a disadvantage by failing to identify patients with surgical coronary artery disease (CAD).

BACKGROUND: In FRISC-II, an invasive strategy provided superior outcomes compared with a conservative strategy for patients with acute coronary syndromes. However, compared with the stress test criteria for crossover to catheterization in the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) trial, the FRISC-II criteria were more restrictive and did not use nuclear imaging or pharmacologic stress testing.

METHODS: We analyzed the conservative arm of VANQWISH to identify the prevalence of surgical CAD in those patients who met the VANQWISH, but not FRISC-II, criteria for catheterization.

RESULTS: Of 385 VANQWISH patients, 90 (23%) met the FRISC-II criteria for catheterization. Another 98 patients (25%) met only VANQWISH stress test criteria (60 patients by exercise and 38 by pharmacologic nuclear stress testing). Among subjects who underwent predischarge angiography, those meeting only VANQWISH stress test criteria had a high prevalence of surgical CAD (51%), comparable to patients who met FRISC-II criteria (54%, p = 0.805).

CONCLUSIONS: The overly stringent risk stratification protocol for conservative-arm patients in FRISC-II could have failed to identify almost as many patients with surgical CAD as it identified. A lower threshold for catheterization in the FRISC-II conservative patients might have improved their outcomes and therefore diminished the putative benefit of an invasive strategy.

Abbreviations and Acronyms   ACC/AHA   American College of Cardiology/American Heart Association   CABG   coronary artery bypass graft surgery   CAD   coronary artery disease   D-MPI   dipyridamole myocardial perfusion imaging   ECG   electrocardiographic/electrocardiogram   EST   exercise stress test/exercise stress testing   FRISC-II   Fast Revascularization During Instability in Coronary Artery Disease   METs   metabolic equivalents   MI   myocardial infarction   TACTICS-TIMI-18   Treat Angina with Aggrastat and Determine Cost of Therapy With an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction-18   VANQWISH   Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital

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