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March 9, 1989New England Journal of Medicine

Reinfarction or death within 42 days occurred in 10.9% of the invasive strategy group and 9.7% of the conservative strategy group (P not significant).

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Why the study?

Does an invasive strategy of early coronary arteriography and prophylactic PTCA reduce reinfarction or death in patients with acute myocardial infarction treated with rt-PA compared to a conservative strategy?

Population

3262 patients with acute myocardial infarction treated with intravenous recombinant tissue plasminogen…

Comparison

Invasive strategy consisting of coronary… vs Conservative strategy where arteriography and…

Design

RCT, randomly assigned

Follow-up

42 days

Discussion

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Overview

Conservative ischemia-guided strategy remains appropriate after rt-PA; confirms no benefit of routine early invasive approach for reducing reinfarction or death.

Key Points

  • To compare clinical outcomes of a routine invasive strategy versus a conservative ischemia-guided strategy in patients with acute myocardial infarction receiving intravenous tissue plasminogen activator.
  • Randomized clinical trial of 3,262 patients treated with intravenous recombinant tissue plasminogen activator (rt-PA) within four hours of acute myocardial infarction onset.
  • Patients were randomized to an invasive strategy (coronary arteriography at 18–48 hours with prophylactic PTCA, n=1,636) or a conservative strategy (angiography and PTCA only for spontaneous or exercise-induced ischemia, n=1,626).
  • A subgroup of 1,390 patients was also randomized to immediate intravenous metoprolol followed by oral dosing versus deferred oral metoprolol initiated on day 6.
  • The primary endpoint of death or reinfarction within 42 days occurred in 10.9% of the invasive strategy group versus 9.7% of the conservative strategy group (P not significant).
  • Resting and exercise ejection fraction showed no significant differences between the invasive and conservative treatment groups at hospital discharge or at 6 weeks.
  • Immediate intravenous metoprolol reduced 6-day nonfatal reinfarction (16 vs 31 patients, P=0.02) and recurrent ischemic episodes (107 vs 147 patients, P=0.005) compared with deferred oral beta-blockade.

Structured PICO

Does an invasive strategy of early coronary arteriography and prophylactic PTCA reduce reinfarction or death in patients with acute myocardial infarction treated with rt-PA compared to a conservative strategy?

P
Population
3262 patients with acute myocardial infarction treated with intravenous recombinant tissue plasminogen activator (rt-PA) within four hours of the onset of chest pain
I
Intervention
Invasive strategy consisting of coronary arteriography 18 to 48 hours after rt-PA administration, followed by prophylactic percutaneous transluminal coronary angioplasty (PTCA) if anatomy was suitable
C
Comparator
Conservative strategy where arteriography and PTCA were performed only for spontaneous or exercise-induced ischemia
O
Outcome
Reinfarction or death within 42 dayscomposite

In patients with acute MI treated with rt-PA, a routine invasive strategy of early coronary arteriography and prophylactic PTCA offered no advantage over a conservative ischemia-guided strategy in reducing mortality or reinfarction.

Cite This Study

A 1989 study studied this question.

synapsesocial.com/papers/6a821adb47f72330e2ffafc2https://doi.org/10.1056/nejm198903093201002
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1The Thrombolysis in Myocardial Infarction (TIMI) Trial1985 · 3,191 citations
  2. 2Rethrombosis after reperfusion with streptokinase: importance of geometry of residual lesions.1984 · 321 citations
  3. 3Intravenous tissue plasminogen activator and size of infarct, left ventricular function, and survival in acute myocardial infarction.1988 · 384 citations
  4. 4A Randomized Trial of Intravenous Tissue Plasminogen Activator for Acute Myocardial Infarction with Subsequent Randomization to Elective Coronary Angioplasty1987 · 357 citations
  5. 5A Randomized Trial of Immediate versus Delayed Elective Angioplasty after Intravenous Tissue Plasminogen Activator in Acute Myocardial Infarction1987 · 945 citations