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(Circulation. 1999;99:1272-1276.)
© 1999 American Heart Association, Inc.

Correspondence

Revascularization After Myocardial Infarction

Peter Bogaty, MD

Quebec Heart Institute Ste-Foy, Quebec, Canada

Gilles R. Dagenais, MD

Department of Medicine University of Montreal, Montreal, Quebec, Canada

To the Editor:

Madsen et al¹ compared an invasive strategy of coronary arteriography and revascularization with a conservative strategy in patients with inducible myocardial ischemia after thrombolysis for a first myocardial infarction. Just over 500 patients aged 69 years and able to perform an exercise test were randomized to each strategy. The invasive-strategy patients underwent 266 angioplasty procedures and 147 bypass operations. There was no significant difference in mortality between the 2 groups at a median of 2.4 years. Rates of reinfarction and of readmission for unstable angina were 5.6% and 17.9%, respectively, for the invasive strategy and 10.5% and 29.5%, respectively, for the conservative strategy. From this, Madsen et al conclude that all subjects with inducible ischemia after a thrombolyzed first myocardial infarction should be revascularized and then extend this sweeping recommendation, without any analysis of costs, days hospitalized, and quality of life, to all postinfarction patients with inducible ischemia.

It is unclear why in this study the invasive strategy's absolute reduction of only 4.9% in the occurrence of myocardial infarction and of 11.6% in the number of admissions for unstable angina over 2.4 years, statistical significance notwithstanding, with no demonstrated reduction in mortality, constitutes sufficient clinical justification for sending all patients with inducible ischemia for coronary revascularization. Should patients with inducible ischemia who are symptomatic and limited to 5 metabolic equivalents (METs) be managed in the same way as asymptomatic patients with inducible ischemia performing 7 METs or >10 METs? Should all patients be similarly treated regardless of . . . [Full Text of this Article]

Jan Kyst Madsen, MD, PhD

Associate Professor

Peer Grande, MD, PhD

Associate Professor Rigshospitalet, Copenhagen, Denmark

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