LETTER TO THE EDITOR
Reply
William E. Boden, MD, FACC* VANQWISH Trial Core Angiographic Laboratory Investigators
* Program Director, Division of Cardiology, The Henry Low Heart Center, at Hartford Hospital, 80 Seymour Street, JB722, Hartford, Connecticut 06102, USA
Dr. Ellestad assails our recent publication (1) on the angiographic findings that characterize the "culprit lesion" in patients with acute non–Q-wave myocardial infarction (MI) as representing "sloppy thinking and sloppy science." We presume this contentious allegation is directed toward our use of the term "non–Q-wave MI," which, along with the comparator term "Q-wave MI," is abhorred by Dr. Ellestad and others (2) who contend that this binary classification system "misrepresents the pathology" of MI and has been termed variably as "a halfway house of the intellect" (3), as having "no basis in scientific fact" (3), and as being "a meaningless distinction" (2). Such pemicious rhetoric serves only to discredit the stature and integrity of the physician assailants and to reinforce the belief that such strong contrarian views are discordant with mainstream cardiology opinion and practice.
At the time that the VANQWISH trial was conducted (1993 to 1996) and reported (1998) (4), the accepted terminology promulgated by both major national cardiology organizations (American College of Cardiology and American Heart Association) consistently endorsed the terms "Q-wave" and "non–Q-wave" MI in their Consensus Management Guidelines (5), suggesting that subject-matter experts and opinion leaders in cardiology did not consider such concepts and terms meaningless or irrelevant.
More recently, of course, the older nomenclature of "Q-wave" and "non–Q-wave" MI has been replaced by a new binary classification system ("ST-segment elevation" and "non–ST-segment elevation" MI), but because our current study was undertaken in an era when the former classification was both widely accepted and used, we decided for the sake of consistency to use the term "non–Q-wave" MI rather than "non–ST-segment elevation" MI in reference to our recent coronary angiographic substudy (1).
We lament Dr. Ellestad’s uncritical assertion that both the JACC editorial staff and the VANQWISH investigators are "ignorant of the pathology of infarction." We are all well aware of the important distinction by which total or subtotal occlusion of the circumflex or obtuse marginal branch coronary circulation can "masquerade" as "non–Q-wave" MI; in fact, we were the first to document (in 1987) the early electrographic findings of true posterior MI (6), based on our careful and comprehensive assessment of serial electrocardiograms (ECGs) in the Diltiazem Reinfarction Trial (7). Moreover, we have contributed significantly to the cardiology literature regarding the important electrocardiographic features of non–Q-wave (non–ST-segment elevation) MI, (8–10) and obviously incorporated these same rigorous criteria for use in the VANQWISH study (4), which, we believe, permitted us to accurately and reliably exclude posterior MI from our study population.
Although our views are unlikely to dissuade Dr. Ellestad and the vocal minority of cardiologists who tenaciously adhere to the holistic notion that "an infarct is an infarct" electrocardiographically, pathogenetically, clinically, angiographically, and prognostically—a view, unfortunately, that ignores and disdains an abundance of scientific information that has been acquired and assimilated over more than 25 years of careful study—we hope that our recent report on the angiographic characteristics of "culprit lesions" will aid more cognitive cardiologists to focus on ways of optimizing the care and management of their patients with non–Q-wave/non–ST-segment elevation MI rather than getting "lost among the forest and trees" of a largely outmoded terminology battle that is of little relevance to contemporary clinical practice.
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References
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1. Kerensky RA, Wade M, Deedwania P, Boden WE, Pepine CJ. Revisiting the culprit lesion in non–Q-wave myocardial infarction: results from the VANQWISH trial angiographic core laboratory. J Am Coll Cardiol. 2002;39:1456–1463[Abstract/Free Full Text]
2. Phibbs B, Marcus F, Marriott HJC, Moss AJ. Q-wave versus non–Q-wave myocardial infarction: a meaningless distinction. J Am Coll Cardiol. 1999;33:576–582[Free Full Text]
3. Phibbs B. "Transmural" versus "subendocardial" myocardial infarction: an electrocardiographic myth. J Am Coll Cardiol. 1983;1:561–564[Medline]
4. Boden WE, O’Rourke RA, Crawford MH, et al. Outcomes in patients with acute non–Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med. 1998;338:1785–1792[Abstract/Free Full Text]
5. Ryan TJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1999;34:890–911[Free Full Text]
6. Diltiazem Reinfarction Study Group, Brown University, Providence, RIBoden WE, Kleiger RE, Gibson RS, Schechtman KB, Capone RJ, Roberts R. Electrocardiographic evolution of posterior myocardial infarction: importance of early precordial S-T-segment depression. Am J Cardiol. 1987;59:782–787[CrossRef][Medline]
7. Gibson RS, Boden WE, Theroux P, et alDiltiazem Reinfarction Study (DRS) Group. Diltiazem and reinfarction in patients with non–Q-wave myocardial infarction: results of a double-blind, randomized multicenter trial. N Engl J Med. 1986;315:423–429[Abstract]
8. Diltiazem Reinfarction Study Group, Brown University, Providence, RIBoden WE, Kleiger RE, Gibson RS, et al. Electrocardiographic and enzymatic findings in acute non–Q-wave myocardial infarction. Am J Noninvas Cardiol. 1988;2:125–133
9. Boden WE, Spodick DH. Diagnostic significance of precordial ST-segment depression. Am J Cardiol. 1989;63:358–361[Medline]
10. Boden WE, Kleiger RE, Gibson RS, et al. Favorable long-term prognosis of acute non–Q-wave myocardial infarction associated with absent or nonspecific electrocardiographic changes. Br Heart J. 1989;61:396–402[Abstract/Free Full Text]
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References