title: Intensive medical therapy versus coronary angioplasty for suppression of myocardial ischemia in survivors of acute myocardial infarction: a prospective, randomized pilot study.
abstract: BACKGROUND
  Patients who have inducible ischemia after acute myocardial infarction (AMI) generally undergo coronary angiography with the intent to revascularize. Whether this approach is superior to intensive treatment with anti-ischemic medications is unknown.
  
  
  RESULTS
  We performed a prospective, randomized pilot study comparing intensive medical therapy with coronary angioplasty (PTCA) for suppression of myocardial ischemia in 44 stable survivors of AMI. Myocardial ischemia was quantified with adenosine 201Tl tomography (SPECT) performed 4.5+/-2.9 days after AMI. All patients at baseline had a large total (>/=20%) and ischemic (>/=10%) left ventricular perfusion defect size (PDS). SPECT was repeated at 43+/-26 days after therapy was optimized. The total stress-induced PDS was comparably reduced with medical therapy (from 38+/-13% to 26+/-16%; P<0.0001) and PTCA (from 35+/-12% to 20+/-16%; P<0.0001). The reduction in ischemic PDS was also similar (P=NS) in both groups. Cardiac events occurred in 7 of 44 patients over 12+/-5 months. Patients who remained clinically stable had a greater reduction in ischemic PDS (-13+/-9%) than those who had a recurrent cardiac event (-5+/-7%; P<0.02). Event-free survival was superior in the 24 patients who had a significant (>/=9%) reduction in PDS (96%) compared with those who did not (65%; P=0.009).
  
  
  CONCLUSIONS
  In this small pilot study, intensive medical therapy and PTCA were comparable at suppressing ischemia in stable patients after AMI. Sequential imaging with adenosine SPECT can track changes in PDS after anti-ischemic therapies and thereby predict subsequent outcome. Corroboration of these preliminary findings in a larger cardiac-event trial is warranted.
authors.affiliation: Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.
authors.forename: H A
authors.initials: HA
authors.lastname: Dakik
authors.forename: N S
authors.initials: NS
authors.lastname: Kleiman
authors.forename: J A
authors.initials: JA
authors.lastname: Farmer
authors.forename: Z X
authors.initials: ZX
authors.lastname: He
authors.forename: J A
authors.initials: JA
authors.lastname: Wendt
authors.forename: C M
authors.initials: CM
authors.lastname: Pratt
authors.forename: M S
authors.initials: MS
authors.lastname: Verani
authors.forename: J J
authors.initials: JJ
authors.lastname: Mahmarian
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D015906:Angioplasty, Balloon, Coronary; D004110:Diltiazem / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007548:Isosorbide Dinitrate / Q000627:therapeutic use*; D008297:Male; D008790:Metoprolol / Q000627:therapeutic use*; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications*; D017202:Myocardial Ischemia / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D010865:Pilot Projects; D011446:Prospective Studies; D015899:Tomography, Emission-Computed, Single-Photon; D014665:Vasodilator Agents / Q000627:therapeutic use*
chemical_list: D000319:Adrenergic beta-Antagonists; D014665:Vasodilator Agents; D004110:Diltiazem; D008790:Metoprolol; D007548:Isosorbide Dinitrate