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
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Figure 1 In-hospital procedures performed at conservative hospitals versus hospitals favoring an early invasive strategy. Patients admitted to hospitals favoring an early invasive strategy were more likely to undergo coronary angiography, coronary angioplasty and coronary artery bypass grafting during their index hospitalization, as well as coronary angiography and coronary angioplasty within 6 h of admission and coronary artery bypass grafting within 24 h of admission. *p < 0.05. Closed bar = conservative; open bar = early invasive.
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Figure 2 Hospital events at conservative hospitals versus hospitals favoring an early invasive strategy. More patients admitted to hospitals favoring a conservative initial strategy developed congestive heart failure during their index hospitalization. Additionally, 30-day mortality was higher at hospitals favoring a conservative initial strategy. MI = myocardial infarction; 30 day death = death within 30 days of index admission. *p < 0.05. Closed bar = conservative; open bar = early invasive.
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Figure 3 Factors associated with a higher risk of death during the index hospitalization in patients admitted to early invasive and hospitals favoring a conservative initial strategy. Odds ratios to the right of the line of identity (odds ratio, 1) are associated with a higher risk of in-hospital mortality. After adjustment for all measured factors that predict mortality, there was a nonsignificant association between admission to hospitals favoring an early invasive strategy and reduced in-hospital mortality (OR = 0.56, 95% CI, 0.29 to 1.093).
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Figure 4 Procedures after discharge at conservative hospitals versus hospitals favoring an early invasive strategy. Patients treated at hospitals favoring an early invasive strategy were more likely to undergo repeat coronary angiography by one and three years. There was no difference in the rate of coronary angioplasty or coronary artery bypass grafting by one or three years. *p < 0.05. Closed bar = conservative; open bar = early invasive.
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Figure 5 Survival rates during follow-up in patients admitted to early invasive and hospitals favoring a conservative initial strategy. In this unadjusted comparison, patients treated at hospitals favoring an early invasive strategy had improved long-term survival (81% vs. 63% at four years, p < 0.001, mean follow-up 3.2 years). Closed square = conservative; open square = early invasive.
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Figure 6 Factors associated with higher risk of death during follow-up in patients admitted to early invasive and hospitals favoring a conservative initial strategy. Hazard ratios to the right of the line of identity (hazard ratio, 1) are associated with a higher risk of long-term mortality. After adjustment for all measured factors that predict mortality, admission to hospitals favoring an early invasive strategy was independently associated with decreased long-term mortality (hazard ratio 0.61, 95% CI, 0.47 to 0.80).
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