Risk stratification after myocardial infarction in the thrombolytic era

Most patients with acute myocardial infarction do not receive or are ineligible for thrombolytic therapy, and thus their prognosis is worse than that of the populations studied in the major, randomized, lytic therapy trials. We need to devise a cost-effective strategy with which to appropriately stratify these patients. Simple, easily ascertained clinical variables that are evident soon after hospital admission can identify higher-risk patients, who are likely to be older and less able to adequately complete an exercise test. In some patients, nuclear imaging tests are appropriate; low-dose dobutamine echocardiography and ambulatory ECG monitoring may also have a role. Greater use of routine cardiac catheterization (with assessment of ventricular function) might be the most appropriate way to stratify patients because it may overcome some of the limitations of noninvasive testing, will clearly define high-risk patients, and may facilitate early discharge from the hospital. Left ventricular function and the patency of the infarct-related artery will be determined, and patients with left main coronary disease, significant three-vessel coronary artery disease, and two-vessel coronary disease (especially with proximal left anterior descending coronary artery involvement) will be identified. An aggressive strategy of revascularization to improve survival in appropriate patients may be employed. Greater use of routine coronary arteriography after acute myocardial infarction would inevitably lower the threshold for inappropriate, potentially risky, and expensive further interventions. We need to focus our attention on the most appropriate strategies for the management of patients whose prognosis is worse than the prognosis of those who receive lytic therapy after acute myocardial infarction.