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Cath Lab for All Patients with Unstable Angina or Non-ST-Segment Elevation MI?

There is continued controversy about whether patients who present with unstable angina or non-ST-segment elevation myocardial infarction should go routinely to the catheterization laboratory. In this study from the Thrombosis In Myocardial Infarction group, 2220 patients were treated with aspirin, heparin, and glycoprotein IIb/IIIa inhibitors and were randomized to an early invasive strategy of catheterization within 48 hours or a conservative strategy in which catheterization was reserved for patients with positive stress tests or other objective evidence of ischemia. The manufacturer of tirofiban supported this study.

At 6 months, the composite primary endpoint of death, nonfatal MI, and rehospitalization had occurred significantly less often in the invasive-strategy group (15.9 percent vs. 19.4 percent). The composite endpoint of death and nonfatal MI also was reduced (7.3 percent vs. 9.5 percent). Patients with elevated troponin T levels at presentation derived the most benefit from early catheterization. About half of the patients in the conservative-strategy group eventually underwent cardiac catheterization during their initial hospitalizations.

Comment: These findings support use of an early invasive strategy in conjunction with GPIIb/IIIa inhibitor therapy for many patients with unstable angina or non-ST-segment elevation MIs, particularly those patients who present with elevated troponin T levels. As an editorialist points out, this trial differed from earlier studies, which showed no benefit for routine angiography, in that GPIIb/IIIa inhibitors and contemporary stenting techniques were used.

— KE Fleischmann

Published in Journal Watch General Medicine July 13, 2001

Citation(s):

Cannon CP et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001 Jun 21 344 1879-1887.

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Boden WE and McKay RG. Optimal treatment of acute coronary syndromes -- An evolving strategy. N Engl J Med 2001 Jun 21 344 1939-1942.

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