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Is there a benefit to early angiography in patients with ST-segment depression myocardial infarction? An
David M Shavelle1, Lori Parsons, Mark J Sada
1Division of Cardiology, University of Washington, Seattle, Wash, USA. dshavelle@hotmail.com
Insights
Very early angiography in ST-segment depression myocardial infarction (MI) did not show a mortality benefit over conservative therapy. After accounting for patient differences, aggressive treatment did not improve in-hospital survival rates.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- ST-segment depression myocardial infarction (MI) patients have outcomes similar to ST-segment elevation MI.
- The benefit of very early (<6 hours) angiography versus early conservative therapy for ST-segment depression MI is not well-established.
Purpose of the Study:
- To compare the short-term outcomes of very early (<6 hours) angiography versus early conservative therapy in ST-segment depression MI patients.
Main Methods:
- Retrospective analysis of the National Registry of Myocardial Infarction 2 (NRMI) database (1994-1998).
- Comparison of patients receiving very early angiography (<6 hours) versus early conservative therapy.
- Outcomes assessed included major bleeding, cerebral vascular events, recurrent ischemia/angina, MI, and death.
Main Results:
- Very early angiography patients were younger, more likely male, smokers, with less cardiac history, and less diabetes.
- No significant differences in cerebral vascular events, major bleeding, or recurrent MI between groups.
- Very early angiography was associated with lower recurrent ischemia/angina and initially appeared to improve survival.
- Multivariate and propensity score analyses revealed no significant in-hospital mortality benefit for very early angiography.
Conclusions:
- The observed mortality benefit of very early angiography is likely due to confounding factors.
- Controlling for baseline differences indicates no in-hospital mortality advantage for an aggressive early approach compared to conservative therapy in ST-segment depression MI.
Background And Objective:
Patients with ST-segment depression myocardial infarction (MI) have a similar long-term outcome compared with those who have ST-segment elevation. It remains unclear whether an aggressive treatment approach with very early (<6 hours) angiography and revascularization improves outcome over an early conservative approach. We compared the short-term outcome of patients who received very early (<6 hours) angiography with patients who received early conservative therapy for ST-segment depression MI.
Methods:
Patients seen within 12 hours with ST-segment depression on the initial electrocardiogram (ECG) were identified from the National Registry of Myocardial Infarction 2 (NRMI) database, which collected information from 1994 to 1998. Those who received very early (<6 hours) angiography were compared with those who received early conservative therapy. The short-term outcomes, including major bleeding episodes, cerebral vascular events, recurrent ischemia and angina, MI, and death, were compared on the basis of the initial therapy received.
Results:
Patients treated with very early angiography (2402) were younger, more likely to be males, smokers, and have less of a cardiac history (angina, MI, congestive heart failure, aortocoronary bypass surgery) and less likely to have diabetes mellitus than those who received early conservative therapy (17,735). Hospital outcome in the very early angiography group was similar to the early conservative therapy group in terms of cerebral vascular events (0.8% vs 1.0%, P =.27), major bleeding events (2.8% vs 2.4%, P =.25), and recurrent MI (2.1% vs 2.3%, P =.57) but was associated with lower recurrent ischemia or angina (11.4% vs 16.7%, P <.001) and improved survival (death, 4.9% vs 7.3%, P <.001). Multivariate analysis suggested that patients receiving very early angiography had lower mortality compared with those receiving early conservative therapy (odds ratio [OR] = 0.76; 95% CI 0.60-0.95). However, comparing patients matched on propensity score (1405) showed mortality was similar in both treatment groups (5.6% vs 5.4%, P =.87), with no significant inhospital mortality benefit of very early angiography (OR = 0.89; 95% CI 0.71-1.13).
Conclusions:
The apparent mortality benefit of very early angiography in patients with ST-segment depression MI is a reflection of bias by confounding. Controlling for baseline differences using propensity score methods in this observational study indicated no inhospital mortality benefit of a very early aggressive approach compared with a conservative approach.