Outcomes in Patients with Acute Non–Q-Wave Myocardial Infarction Randomly Assigned to an Invasive as Compared with a Conservative Management Strategy

Boden, William E.; O’Rourke, Robert A.; Crawford, Michael H.; Blaustein, Alvin S.; Deedwania, Prakash; Zoble, Robert G.; Wexler, Laura; Kleiger, Robert E.; Pepine, Carl J.; Ferry, David; Chow, Bruce K.; Lavori, Philip W.

doi:10.1056/nejm199806183382501

Cited by 734 publications

(196 citation statements)

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“…We excluded 31 articles for the following reasons (Appendix): Not a randomized controlled trial (n ϭ 8), studied patients without non-ST elevation ACS (n ϭ 17), did not study routine versus selective coronary angiography (n ϭ 4), or presented secondary findings of a trial (n ϭ 2). After this review, eight reports representing the primary outcomes of eight unique trials remained (21)(22)(23)(24)(25)(26)(27)(28). Investigators from all trials were contacted, but serum creatinine had not been recorded in three of them (23,26,27).…”

Section: Search Resultsmentioning

confidence: 99%

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Early Angiography in Patients with Chronic Kidney Disease

Charytan

Wallentin

Lagerqvist

et al. 2009

Clinical Journal of the American Society of Nephrology

106

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Background and objectives: In the general population, an early invasive strategy of routine coronary angiography is superior to a conservative strategy of selective angiography in patients who are admitted with unstable angina or non-ST segment elevation myocardial infarction (MI), but the effectiveness of this strategy in individuals with chronic kidney disease (CKD) is uncertain.Design, setting, participants, & measurements: We conducted a collaborative meta-analysis with data provided by the main authors of identified trials to estimate the effectiveness of early angiography in patients with CKD. The Cochrane, Medline, and EMBASE databases were searched to identify randomized trials that compared invasive and conservative strategies in patients with unstable angina or non-ST MI. Pooled risks ratios were estimated using data from enrolled patients with estimated GFR <60 ml/min per 1.73 m 2 . Results: Five randomized trials that enrolled 1453 patients with CKD were included. An early invasive strategy was associated with nonsignificant reductions in all-cause mortality, nonfatal MI, and a composite of death or nonfatal MI. The invasive strategy significantly reduced rehospitalization.Conclusions: This collaborative study suggests that the benefits of an early invasive strategy are preserved in patients with CKD and that an early invasive approach reduces the risk for rehospitalization and is associated with trends of reduction in the risk for death and nonfatal re-infarction in patients with CKD. Coronary angiography should be considered for patients who have CKD and are admitted with non-ST elevation acute coronary syndromes.

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Section: Search Resultsmentioning

confidence: 99%

“…After this review, eight reports representing the primary outcomes of eight unique trials remained (21)(22)(23)(24)(25)(26)(27)(28). Investigators from all trials were contacted, but serum creatinine had not been recorded in three of them (23,26,27). The remaining five trials (Table 1) served as the basis of our analysis.…”

Section: Search Resultsmentioning

confidence: 99%

Early Angiography in Patients with Chronic Kidney Disease

Charytan

Wallentin

Lagerqvist

et al. 2009

Clinical Journal of the American Society of Nephrology

106

View full text Add to dashboard Cite

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“…And, there is a potential for early hazard due to intervention on unstable plaques with fresh thrombus. [24][25][26] FIVE YEAR FOLLOW-UP RESULTS IN THE COREA-AMI REGISTRY Conversely, a relative delayed strategy in NSTEMI might offer benefits through plaque passivation by optical medical treatment followed by intervention on more stable plaques. 27,28) Also, the role of ischemic preconditioning could offer substantial protection in NSTEMI patients.…”

Section: Discussionmentioning

confidence: 99%

Impact of Postprocedural TIMI Flow on Long-Term Clinical Outcomes in Patients with Acute Myocardial Infarction

et al. 2017

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SummaryThis study aimed to evaluate the clinical prognostic implications of postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow in acute myocardial infarction patients. A total of 2796 ST-elevation myocardial infarction (STEMI) and 1720 non ST-elevation myocardial infarction (NSTEMI) patients treated in 8 hospitals affiliated with the Catholic University of Korea and Chonnam National University Hospital were analyzed. The study populations were divided according to the final TIMI flow. The primary outcome were the major adverse cardiac events (MACE), defined as a composite of cardiac deaths (CD), nonfatal myocardial infarctions (MI), and target lesion revascularization (TLR). Over a median follow-up of 3.3 years (minimum 2 to maximum 5 years), MACE and CD occurred more frequently in STEMI patients with TIMI !2 group than those with TIMI 3 (MACE: adjusted hazard ratio [aHR], 1.962; 95% confidence interval [CI] 1.513 to 2.546, P < 0.001, CD: aHR, 3.154, CI 2.308 to 4.309, P < 0.001). However, there was no significant difference between the two subgroups in NSTEMI (aHR, 0.932; 95% CI 0.586 to 1.484, P = 0.087). In STEMI patients, good postprocedural TIMI flow after PCI was associated with favorable clinical outcomes. And the effect of poor TIMI flow in STEMI was on death, not the components of MACE. Meanwhile, postprocedural TIMI flow had no effect on long-term outcomes in NSTEMI patients.(Int Heart J 2017; 58: 674-685)

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“…However, it seems unlikely that awareness of ST-segment status in lead aVR had had a major impact on the description of coronary lesions. Because a widespread use of an early invasive therapeutic strategy in the large and heterogeneous population of patients with non-ST-segment elevation AMI might be costineffective 29,30 or even harmful in those at the lowest risk, 31 identification of the subsets likeliest to benefit from this strategy is a focus of continued attention. 12,13 Accordingly, and in view of its association with severe coronary artery disease, ST-segment elevation in lead aVR could be used, if the results of the present study are confirmed in the large databases now available, as a readily available tool for an early selection of patients for coronary angiography and revascularization.…”

Section: Discussionmentioning

confidence: 99%

Prognostic Value of Lead aVR in Patients With a First Non–ST-Segment Elevation Acute Myocardial Infarction

et al. 2003

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Background-ST-segment elevation in lead aVR has been associated with severe coronary artery lesions in patients with acute coronary syndromes, but the prognostic significance of this finding is unknown. Methods and Results-We analyzed the initial ECG in 775 consecutive patients admitted to our center with a first acute myocardial infarction without ST-segment elevation in leads other than aVR or V 1 . The rates of in-hospital death in patients without (nϭ525) and with 0.05 to 0.1 mV (nϭ116) or Ն0.1 mV (nϭ134) of ST-segment elevation in lead aVR were 1.3%, 8.6%, and 19.4%, respectively (PϽ0.001). After adjustment for the baseline clinical predictors and for ST-segment depression on admission, the odds ratios for death in the last 2 groups were, respectively, 4.2 (95% CI, 1.5 to 12.2) and 6.6 (95% CI, 2.5 to 17.6). The rates of recurrent ischemic events and heart failure during hospital stay also increased in a stepwise fashion among the groups, whereas creatine kinase-MB levels were similar. Among the 437 patients that were catheterized within 6 months, the prevalence of left main or 3-vessel coronary artery disease in the 3 groups was 22.0%, 42.6%, and 66.3%, respectively (PϽ0.001). Conclusions-Lead aVR contains important short-term prognostic information in patients with a first non-ST-segment elevation acute myocardial infarction. Because the poorer outcome predicted by ST-segment elevation in lead aVR seems to be related to a more severe coronary artery disease, an early invasive approach might be especially beneficial in patients presenting with this finding.

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Outcomes in Patients with Acute Non–Q-Wave Myocardial Infarction Randomly Assigned to an Invasive as Compared with a Conservative Management Strategy

Abstract: Most patients with non-Q-wave myocardial infarction do not benefit from routine, early invasive management consisting of coronary angiography and revascularization. A conservative, ischemia-guided initial approach is both safe and effective.

Cited by 734 publications

References 40 publications

Early Angiography in Patients with Chronic Kidney Disease

Early Angiography in Patients with Chronic Kidney Disease

Impact of Postprocedural TIMI Flow on Long-Term Clinical Outcomes in Patients with Acute Myocardial Infarction

Prognostic Value of Lead aVR in Patients With a First Non–ST-Segment Elevation Acute Myocardial Infarction

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