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J Am Coll Cardiol, 2006; 48:2458-2467, doi:10.1016/j.jacc.2006.07.068 (Published online 28 November 2006). © 2006 by the American College of Cardiology Foundation

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CLINICAL RESEARCH: POST-INFARCTION MYOCARDIAL PERFUSION IMAGING

An Initial Strategy of Intensive Medical Therapy Is Comparable to That of Coronary Revascularization for Suppression of Scintigraphic Ischemia in High-Risk But Stable Survivors of Acute Myocardial Infarction

John J. Mahmarian, MD^_*,1,_*, Habib A. Dakik, MD, Neil G. Filipchuk, MD^,3, Leslee J. Shaw, PhD^,2, Sherif S. Iskander, MD^||,4, Terrence D. Ruddy, MD^¶, Felix Keng, MD^#, Milena J. Henzlova, MD^_**,4, Adel Allam, MD, Lemuel A. Moyé, MD, PhD, Craig M. Pratt, MD^_* for the INSPIRE Investigators

^_* Methodist DeBakey Heart Center, Department of Cardiology, The Methodist Hospital, Houston, Texas
American University of Beirut, Beirut, Lebanon
University of Calgary, Calgary, Alberta, Canada
Cedars-Sinai Medical Center, Los Angeles, California
^|| Cardiovascular Associates of East Texas, Tyler, Texas
^¶ University of Ottawa Heart Institute, Ottawa, Ontario, Canada
^# National Heart Centre, Singapore, Singapore
^_** Mount Sinai Medical Center, New York, New York
Al-Azhar University, Cairo, Egypt
University of Texas School of Public Health, Houston, Texas.

Manuscript received March 30, 2006; revised manuscript received July 5, 2006, accepted July 6, 2006.

^_* Reprint requests and correspondence: Dr. John J. Mahmarian, Department of Cardiology, Methodist DeBakey Heart Center, 6550 Fannin Street, SM-677, Houston, Texas 77030. (Email: jmahmarian{at}tmh.tmc.edu).

OBJECTIVES: The purpose of this study was to determine the relative benefit of intensive medical therapy compared with coronary revascularization for suppressing scintigraphic ischemia.

BACKGROUND: Although medical therapies can reduce myocardial ischemia and improve patient survival after acute myocardial infarction, the relative benefit of medical therapy versus coronary revascularization for reducing ischemia is unknown.

METHODS: A prospective randomized trial in 205 stable survivors of acute myocardial infarction was made to define the relative efficacy of an intensive medical therapy strategy versus coronary revascularization for suppressing scintigraphic ischemia as assessed by serial gated adenosine Tc-99m sestamibi myocardial perfusion tomography. All patients at baseline had large total (20%) and ischemic (10%) adenosine-induced left ventricular perfusion defects and an ejection fraction 35%. Imaging was performed during 1 to 10 days of hospital admission and repeated in an identical fashion after optimization of therapy. Patients randomized to either strategy had similar baseline demographic and scintigraphic characteristics.

RESULTS: Both intensive medical therapy and coronary revascularization induced significant but comparable reductions in total (–16.2 ± 10% vs. –17.8 ± 12%; p = NS) and ischemic (–15 ± 9% vs. –16.2 ± 9%; p = NS) perfusion defect sizes. Likewise, a similar percentage of patients randomized to medical therapy versus coronary revascularization had suppression of adenosine-induced ischemia (80% vs. 81%; p = NS).

CONCLUSIONS: Sequential adenosine sestamibi myocardial perfusion tomography can effectively monitor changes in scintigraphic ischemia after anti-ischemic medical or coronary revascularization therapy. A strategy of intensive medical therapy is comparable to coronary revascularization for suppressing ischemia in stable patients after acute infarction who have preserved LV function.

Abbreviations and Acronyms   ADSPECT = adenosine technetium-99m sestamibi single-photon emission computed tomography   AMI = acute myocardial infarction   BB = beta-blockers   CABG = coronary artery bypass grafting   CAD = coronary artery disease   CCB = calcium-channel blocker   EF = ejection fraction   LAD = left anterior descending   LV = left ventricular   PCI = percutaneous coronary intervention   PDS = perfusion defect size

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