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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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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.

View larger version (17K): [in this window] [in a new window] [Download PPT slide]   Figure 1 Absolute mean (± SD) change in scintigraphic variables in 169 randomized patients who had 2 adenosine single-photon tomographic (SPECT) studies. LV = left ventricle; LVEF = left ventricular ejection fraction; PDS = perfusion defect size.

View larger version (19K): [in this window] [in a new window] [Download PPT slide]   Figure 2 Primary end point: absolute mean (± SD) and individual changes in total and ischemic left ventricular (LV) perfusion defect size (PDS) from SPECT-1 to SPECT-2 study in the 2 randomized groups. The dashed line represents a 9% reduction in PDS (i.e., 95% confidence interval for a real patient change). Other abbreviations as in Figure 1.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 3 Serial SPECT images and polar plot of a patient randomized to medical therapy. Baseline SPECT (A) shows a large perfusion defect (arrows) in the short (SA), horizontal long (HLA), and vertical long (VLA) axis slices after stress (upper panels) which improves with rest imaging (lower panels). Ischemia is present in the right and circumflex vascular territories. Total LV PDS is 30% with 25% ischemia (green) and 5% scar (black). The patient was treated with a beta-blocker, calcium-channel blocker, and statin. Repeat SPECT (B) is entirely normal. This patient had no subsequent cardiac event. Other abbreviations as in Figure 1.

View larger version (18K): [in this window] [in a new window] [Download PPT slide]   Figure 4 Patient outcome based on randomized treatment strategy.