Routine angiography shows early benefits
Angio should be driven by clinical events
A recent study concluded that early, routine angiography reduces the rate of early complications in patients with acute coronary syndromes who are ineligible for thrombolytics.1 However, the study found no long-term improvements in outcome, leaving the question of whether these patients should undergo routine catheterization.
"Our primary hypothesis was that we could show an early benefit, and indeed we were able to illustrate it," said Peter A. McCullough, MD, of Henry Ford Hospital in Detroit, in a statement. "However, when we followed patients for 21 months, we found that the rate of recurrent heart attack or death was equal in both groups. This poses a very difficult question: Should we forgo an early benefit because we cannot detect a longer term difference in recurrent heart attacks or death?"
In the Medicine Vs. Angiography in Thrombolytic Exclusion (MATE) trial, McCullough and other investigators randomized 200 heart attack patients ineligible for clot-buster therapy to either an aggressive strategy of early triage angiography and subsequent therapies based on the angiogram or conservative medical care with drugs. As a result of the early angiogram, more than half of patients in the aggressive group underwent bypass surgery or balloon angioplasty. In the conservative group, 60% of patients eventually required angiography because of recurrent ischemia, and 37% eventually required revascularization. The in-hospital rate of recurrent ischemic events or death was 13% in the aggressive group vs. 34% in the conservative group. There were no differences between the groups with respect to initial hospital costs or length of stay, and long-term follow-up revealed no significant differences in late revascularizations, recurrent infarctions, or mortality.
"Our study supports the idea of performing early angiography when it is clinically indicated," commented McCullough. "Based on our study and others, angiography should not be programmatically applied to all patients. Instead, angiography should be driven by a clinical event such as recurrent ischemia."
Reference
1. McCullough PA, O'Neill WW, Graham M, et al. A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. J Am Coll Cardiol 1998;32:596-605.
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