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Does Early Angiography Improve Outcomes in Non-ST Elevation AMI?

Early intervention to open infarct-related arteries in patients with acute MI with ST-segment elevation clearly reduces mortality. Rapid angiography and intervention to stabilize presumed culprit lesions in patients with acute MI without ST elevation seems rational, but the benefit of this approach has not been documented. These investigators retrospectively analyzed a subset of patients from the Myocardial Infarction Triage and Intervention (MITI) registry that comprised 12,331 consecutive patients with acute MI.

The cohort included patients who exhibited elevated CK-MB levels but no ST elevation on the initial ECG; patients with cardiogenic shock were excluded. Of the 1635 patients in the cohort, 308 were admitted to 2 hospitals that preferred an invasive approach (defined as performance of cardiac catheterization within 6 hours of admission on at least 25% of patients with chest pain and nondiagnostic ECGs), and 1327 were admitted to 17 hospitals that followed a more conservative strategy. Patients admitted to the hospitals with invasive strategies were significantly more likely to undergo early coronary angiography (59% vs. 8%; P<0.001) and angioplasty (45% vs. 6%; P<0.001). After adjustment for predictors of mortality, there was a nonsignificantly lower 30-day mortality in the invasive group (OR, 0.56; 95% CI, 0.25-1.21). Long-term (mean, 3.2 years) adjusted mortality was significantly lower in the invasive group (hazard ratio, 0.63; 95% CI, 0.47-0.83).

Comment: The findings from this provocative study suggest that early aggressive intervention can reduce mortality in patients with acute coronary syndromes without ST-segment elevation. Selection bias could have influenced outcome in this retrospective analysis, but these findings argue strongly for a prospective, randomized study.

— JM Christenson

Published in Journal Watch Emergency Medicine May 1, 2000

Citation(s):

Scull GS et al. Early angiography versus conservative treatment in patents with non-ST elevation acute myocardial infarction. J Am Coll Cardiol 2000 Mar 15 35 895-902.

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