(Circulation. 1995;92:1101-1109.)
© 1995 American Heart Association, Inc.
Articles |
Effect of Infarct Artery Patency on Prognosis After Acute Myocardial Infarction
From the Mount Sinai Medical Center, Miami Beach, and the University of Miami (Fla) School of Medicine (G.A.L.); the University of Missouri Hospitals and Medical School, Columbia (G.F.); the Brigham and Women's Hospital and Harvard Medical School, Boston, Mass (G.M., M.A.P., E.B.); the University of North Carolina School of Medicine, Chapel Hill (S.C.S.); Georgetown University Hospital and Medical School, Washington, DC (B.J.G.); the University of Texas Health Sciences Center, Houston (C.-C.W., L.M.); the University of Texas Southwestern Medical Center, Dallas (J.D.R.); and the Montreal Heart Institute (J.L.R.).
Background In patients with acute myocardial infarction (MI), early restoration of patency of the infarct-related artery (IRA) leads to preservation of left ventricular function and improved clinical outcome. However, there is evidence that the benefits associated with a patent IRA are out of proportion to the observed improvement in ventricular function and may result not only from salvage of ischemic myocardium but also from the opening of the IRA beyond a narrow postinfarct time window. The objectives of this study were (1) to assess the effect of IRA patency on outcome of patients after acute MI with left ventricular dysfunction while controlling for differences in left ventricular ejection fraction and the extent of coronary disease and (2) to determine the effect of angiotensin-converting enzyme (ACE) inhibitor therapy on patients with patent as well as occluded infarct arteries.
Methods and Results The Survival and Ventricular
Enlargement (SAVE) study consisted of 2231 patients with a documented
MI and a left ventricular ejection fraction 
40%. They
were randomized to the ACE inhibitor captopril (50 mg TID)
or placebo 3 to 16 days after MI and were followed for an average of
3.5 years. Left ventricular ejection fraction, measured
with radionuclide left ventriculography, was repeated at the end of the
follow-up period. The 946 patients in whom the patency of the IRA was
established before randomization form the basis of this study. At
cardiac catheterization averaging 4.2 days after
infarction, 30.7% of patients had an initially occluded IRA. After
revascularization, 162 of the 946 patients (17.1%)
were left with an occluded IRA at the time of randomization. The 162
patients with persistently occluded IRAs and 784 with patent IRAs had
similar clinical baseline characteristics, but those with occluded
arteries had a slightly lower ejection fraction than the 784 patients
with patent infarct arteries (30% versus 32%, P=.01). Cox
proportional-hazards analyses showed that the independent
predictors of all-cause mortality were hypertension (relative risk
[RR] 1.94, P<.001), number of diseased coronary
arteries (RR 1.68, P<.001), occluded IRA (RR 1.49,
P=.039), ejection fraction (RR 1.36, P<.001),
age (RR 1.10, P=.030), and use of ß-adrenergic receptor
blocking agents (RR 0.60, P=.007). Independent predictors of
a composite end point consisting of cardiovascular
mortality, morbidity, or reduction of ejection fraction of 
9 units
were occluded IRA (odds ratio [OR] 1.73, P=.002),
hypertension (OR 1.71, P<.001), number of diseased vessels
(OR 1.38, P<.001), ejection fraction (OR 1.18,
P=.003), use of ß-adrenergic receptor blocking agents (OR
0.67, P=.007), and randomization to captopril (OR 0.70,
P=.009).
Conclusions IRA patency within 16 days after MI predicts a favorable clinical outcome, independent of the number of obstructed coronary arteries or of left ventricular function. The beneficial effect of ACE inhibition is independent of patency status of the IRA. These findings support the need for additional, prospective clinical trials of late reperfusion in MI patients.
Key Words: myocardial infarction • arteries • captopril • ventricles • receptors, adrenergic, beta
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