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Is Routine Angiography Warranted After Non-Q-Wave MI?

In the U.S., many patients with acute non-Q-wave myocardial infarction are routinely offered coronary angiography, often followed by revascularization. Is this aggressive strategy warranted? Veterans Affairs researchers randomized 920 patients with non-Q-wave MI to receive either routine angiography a few days after the MI (invasive management) or angiography only for postinfarction angina or abnormalities on predischarge stress-thallium testing (conservative management).

Nearly all patients in the invasive group, but only 24 percent in the conservative group, had angiography before hospital discharge. During an average follow-up of two years, rates of revascularization (bypass surgery or angioplasty) were 44 percent in the invasive group and 33 percent in the conservative group. A combined endpoint of death or recurrent nonfatal MI was significantly more frequent in the invasive group at hospital discharge (36 vs. 15 events) and at one year (111 vs. 85 events). Mortality, considered alone, was also significantly higher with the invasive strategy at discharge and one year. At two years, differences between groups were statistically nonsignificant for both the combined endpoint and mortality.

Comment: Editorialists note that this is the fourth trial comparing aggressive with conservative management after acute coronary syndromes. Taken together, the trials suggest no advantage -- and possibly harm -- from the aggressive approach. It will be interesting to see if these results lead to changes in U.S. practice.

— AS Brett

Published in Journal Watch General Medicine June 26, 1998

Citation(s):

Boden WE 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 Jun 18 338 1785-1792.

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• Medline abstract (Free)

Lange RA and Hillis LD. Use and overuse of angiography and revascularization for acute coronary syndromes. N Engl J Med 1998 Jun 18 338 1838-1839.

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• Medline abstract (Free)