Key result
Among patients with a first non-Q wave myocardial infarction, an early invasive strategy resulted in higher rates of death or MI at 12 months compared to a conservative strategy (20% vs 12%, P=0.016).
Why the study?
Does an early invasive strategy reduce death or myocardial infarction compared to a conservative strategy in patients with non-Q wave myocardial infarction with or without prior MI?
RCT (n=920)
randomized
Does an early invasive strategy reduce death or myocardial infarction compared to a conservative strategy in patients with non-Q wave myocardial infarction with or without prior MI?
In patients with a first non-Q wave myocardial infarction, a conservative, ischemia-guided strategy may yield better outcomes at 1 year compared to an early invasive strategy, whereas those with prior MI have similar outcomes with either approach.
Answers are grounded in this paper and cite their sources.
Early invasive strategy raises 1-year death or MI risk in first non-Q wave MI; challenges routine invasive management and supports conservative approach.
AIMS: To compare the role of early invasive vs conservative management strategies in treating patients with non-Q wave myocardial infarction with or without a prior myocardial infarction. BACKGROUND: In patients recovering from non-Q wave myocardial infarction, the prognosis among patients with a first non-Q wave myocardial infarction is significantly better than in patients with a prior myocardial infarction, yet physicians often adopt an early invasive strategy to treat patients with a first non-Q wave myocardial infarction. METHODS: Non-Q wave myocardial infarction patients enrolled in the VANQWISH trial with a history of prior myocardial infarction were compared to those with a first non-Q wave myocardial infarction, for the trial primary end-point of death or myocardial infarction at 1 and 12 months, as well as for the initial randomized treatment strategy. RESULTS: Of the 920 non-Q wave myocardial infarction patients, 396 had a history of prior myocardial infarction and 524 did not. Patients with a history of prior myocardial infarction were older and had a higher incidence of multiple high-risk baseline characteristics than those with a first non-Q wave myocardial infarction. Compared to the group with a first myocardial infarction, the prior myocardial infarction group suffered more events at both 1 month (11% vs 6%, P=0.007) and at 12 months (29% vs 16%, P<0.001). This difference in outcome remained significant even after adjusting for confounding variables (P<0.0001 at 12 months). Among the non-Q wave myocardial infarction patients with a prior myocardial infarction, the frequency of death or recurrent myocardial infarction was similar in both invasive and conservative groups during the first year of follow-up. Among the first non-Q wave myocardial infarction group, those assigned to the conservative strategy had significantly fewer events (3% vs 9%, P=0.009 at 1 month; 12% vs 20%, P=0.016 at 12 months) and mortality (1% vs 5%, P=0.012 at one month; 5% vs 11%, P=0.009 at 12 months) than those assigned to early invasive strategy. CONCLUSION: A history of prior myocardial infarction identifies a moderately high-risk subset of non-Q wave myocardial infarction patients who display similar long-term outcomes regardless of the strategy assignment; however, patients with a first non-Q wave myocardial infarction may fare better with a conservative or ischaemia-guided approach during the first post infarction year.
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Prabhakara Shetye Heggunje (2000) conducted an RCT in Non-Q wave myocardial infarction (n=920). Early invasive strategy vs. Conservative or ischaemia-guided strategy was evaluated on Death or myocardial infarction at 12 months (first MI subgroup) (p=0.016). Among patients with a first non-Q wave myocardial infarction, an early invasive strategy resulted in higher rates of death or MI at 12 months compared to a conservative strategy (20% vs 12%, P=0.016).
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