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[Should coronary angiography be practiced in patients with recent myocardial infarction?]
1Service de cardiologie, Centre hospitalier, Saint-Germain-en-Laye.
Insights
Early coronary arteriography is often unnecessary for myocardial infarction. Noninvasive testing before discharge can identify low-risk patients, avoiding routine invasive procedures.
Area of Science:
- Cardiology
- Vascular Medicine
- Diagnostic Imaging
Background:
- Myocardial infarction typically results from occlusive thrombosis in atherosclerotic stenosis.
- Intravenous thrombolysis and salvage angioplasty are common interventions, but coronary arteriography is feasible for a minority.
- Early coronary arteriography is not always indicated, especially in low-risk infarction cases.
Purpose of the Study:
- To evaluate the necessity of systematic coronary arteriography in patients with myocardial infarction.
- To identify reliable noninvasive methods for risk stratification post-infarction.
- To determine the optimal management strategy balancing intervention benefits and risks.
Main Methods:
- Retrospective analysis of patient outcomes following myocardial infarction.
- Inclusion of clinical data, echocardiography, and stress test results (including isotopic studies).
- Stratification of patients based on noninvasive evaluation before hospital discharge.
Main Results:
- Approximately 80% of patients experience an uneventful initial period post-infarction.
- One-year mortality is influenced by residual ischemia and left ventricular dysfunction.
- Noninvasive evaluation identified a group (40%) with <3% one-year mortality, suggesting lower risk.
Conclusions:
- Systematic coronary arteriography is not justified for all myocardial infarction patients.
- Noninvasive risk stratification before discharge is crucial for identifying suitable candidates for conservative management.
- Routine angioplasty without evidence of exercise-induced ischemia lacks demonstrated benefit.
Abstract:
As a rule, infarction results from an occlusive thrombosis in a pre-existing atherosclerotic stenosis. Contrary to intravenous thrombolysis, coronary arteriography with immediate removal of obstruction can only be performed in a minority of patients. Similarly, "salvage angioplasty", performed if thrombolysis has failed, does not justify early coronary arteriography, except in certain cases of infarction at very high risk. In 80% of the cases the first days are uneventful, but the mortality in the first year (about 10%) will depend upon the presence or absence of latent residual ischaemia and/or left ventricular dysfunction. A noninvasive evaluation carried out before the patient is discharged and including clinical and echocardiographic data as well as the results of stress tests (sometimes coupled with isotopic studies) may isolate an important group of patients (40%) whose mortality rate at one year is below 3%. Systematic coronary arteriography, therefore, is not justified, especially since it facilitates the "easy" decisions of angioplasty the benefits of which has not been demonstrated in the absence of residual ischaemia during exercise.