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(Circulation. 1998;98:2017-2023.)
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports |
Intensive Medical Therapy Versus Coronary Angioplasty for Suppression of Myocardial Ischemia in Survivors of Acute Myocardial Infarction
A Prospective, Randomized Pilot Study
Presented in part at the 46th Scientific Sessions of the American College of Cardiology, Anaheim, Calif, March 17, 1997 and published in abstract form (J Am Coll Cardiol. 1997;29(suppl A):53A.
From the Section of Cardiology, Baylor College of Medicine, Houston, Tex.
Correspondence to John J. Mahmarian, MD, 6550 Fannin St, SM-1246, Houston, TX 77030-2716. E-mail johnj{at}bcm.tmc.edu
Background—Patients who have inducible ischemia after acute myocardial infarction (AMI) generally undergo coronary angiography with the intent to revascularize. Whether this approach is superior to intensive treatment with anti-ischemic medications is unknown.
Methods and Results—We performed a prospective, randomized pilot
study comparing intensive medical therapy with coronary
angioplasty (PTCA) for suppression of myocardial ischemia in 44
stable survivors of AMI. Myocardial ischemia was quantified
with adenosine 201Tl tomography (SPECT) performed
4.5±2.9 days after AMI. All patients at baseline had a large total
(
20%) and ischemic (10%) left ventricular
perfusion defect size (PDS). SPECT was repeated at 43±26 days after
therapy was optimized. The total stress-induced PDS was comparably
reduced with medical therapy (from 38±13% to 26±16%;
P<0.0001) and PTCA (from 35±12% to 20±16%;
P<0.0001). The reduction in ischemic PDS was
also similar (P=NS) in both groups. Cardiac events
occurred in 7 of 44 patients over 12±5 months. Patients who remained
clinically stable had a greater reduction in ischemic PDS
(-13±9%) than those who had a recurrent cardiac event (-5±7%;
P<0.02). Event-free survival was superior in the 24
patients who had a significant (9%) reduction in PDS (96%) compared
with those who did not (65%; P=0.009).
Conclusions—In this small pilot study, intensive medical therapy and PTCA were comparable at suppressing ischemia in stable patients after AMI. Sequential imaging with adenosine SPECT can track changes in PDS after anti-ischemic therapies and thereby predict subsequent outcome. Corroboration of these preliminary findings in a larger cardiac-event trial is warranted.
Key Words: myocardial infarction • tomography • ischemia
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