Reevaluation of routine invasive strategy versus noninvasive testing following uncomplicated ST-elevation myocardial infarction.
OBJECTIVE
While current guidelines recommend a selective invasive approach after low-risk ST-elevation myocardial infarction (STEMI) treated by thrombolysis, based on noninvasive identification of patients with residual or inducible myocardial ischemia, in many instances physicians employ a strategy of routine angiography. The present study was undertaken to reexamine the correlation between noninvasive testing and coronary angiography in patients recovering from uncomplicated STEMI with regard to detection and management of residual infarct artery stenosis and to identify patients with multivessel (MVD) or high-risk coronary disease.


METHODS
We prospectively performed predischarge exercise testing (ETT) and myocardial perfusion scintigraphy (MPS) prior to routine predischarge coronary angiography in 83/276 consecutive STEMI patients, who after treatment with initial and early thrombolysis, were defined as low risk by ACC/AHA risk classification.


RESULTS
ETT was positive for myocardial ischemia in 11/43 (26%) patients with single-vessel disease (SVD) and 11/22 (50%) patients with MVD, but normal or nondiagnostic in the remainder. MPS revealed significant reversible perfusion defects in 13/40 (32%) patients with SVD and 13/22 (59%) patients with MVD. A selective strategy of ETT followed by MPS for nondiagnostic ETT missed residual infarct-related artery stenosis and/or MVD in 31/81 (38%) of the cohort. Among patients who may not otherwise have been referred for angiography, severe (> or =70%) residual stenosis of the infarct-related artery was present in 56% and MVD in 16%.


CONCLUSIONS
Early predischarge ETT and/or MPS had limited sensitivity for the detection of coronary disease in low-risk post-STEMI patients. The study supports a simpler strategy of routine coronary angiography in most patients after low-risk STEMI.
Department of Cardiovascular, Lady Davis Carmel Medical Center, Technion-Israel Institute of Technology, Haifa, Israel.
Ronen
R
Jaffe
David A
DA
Halon
Simona
S
Ben Haim
Avinoam
A
Shiran
Sarah
S
Gips
Basheer
B
Karkabi
Avi
A
Front
Yaakov
Y
Goldstein
Ronen
R
Rubinshtein
Moshe Y
MY
Flugelman
Basil S
BS
Lewis
D017023:Coronary Angiography; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D009204:Myocardial Revascularization / Q000379:methods*; D011446:Prospective Studies; D011877:Radionuclide Imaging; D012042:Registries; D015912:Thrombolytic Therapy; D016896:Treatment Outcome