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Coronary Angiography and Angioplasty after Acute Myocardial Infarction

David W. Bates, MD, MSc; Elizabeth Miller, BS; Steven J. Bernstein, MD; Paul J. Hauptman, MD; and Lucian L. Leape, MD
[+] Article and Author Information

From Brigham and Women's Hospital and Harvard School of Public Health, Boston, Massachusetts; and University of Michigan Medical Center, Ann Arbor, Michigan. Acknowledgments: The authors thank George Beller, MD, Gottlieb C. Friesinger, MD, Spencer B. King 3d, MD, Thomas J. Ryan, MD, and Eric J. Topol, MD, for their comments on an earlier version of this manuscript. Grant Support: By research grant R01-HS08071-02 from the Agency for Health Care Policy and Research. Requests for Reprints: David W. Bates, MD, MSc, Division of General Medicine and Primary Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Current Author Addresses: Dr. Bates and Ms. Miller: Division of General Medicine and Primary Care, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;126(7):539-550. doi:10.7326/0003-4819-126-7-199704010-00007
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Purpose: To assess the data that support the use of coronary angiography and angioplasty after acute myocardial infarction, that identify the risks of these procedures, and that analyze their use and costs.

Data Sources: English-language articles published between 1970 and June 1995 identified through a search of the MEDLINE database.

Study Selection: Studies that contained information about benefits, risks, use, and costs of coronary angiography and angioplasty after acute myocardial infarction.

Data Extraction: Descriptive and analytic data from each study were collected.

Data Synthesis: The outcome for patients who have complications of myocardial infarction (such as shock) is poor. Such patients usually undergo angiography, although the evidence that supports this practice is weak. Preliminary data suggest that patients who immediately have angiography and angioplasty after acute myocardial infarction have better outcomes than do patients who receive thrombolytic therapy with angioplasty only for specific indications in experienced centers. After the acute phase of myocardial infarction, patients who have noninvasive evidence of persistent or recurrent ischemia are believed to benefit from angiography. In the remaining patients, however, angiography after myocardial infarction has not been shown to be beneficial. Coronary angiography is done in 30% to 81% of patients after acute myocardial infarction in different settings and regions; for many of these patients, the benefit is questionable. Better outcomes are not always associated with more frequent use of the procedure. In the United States, catheterizations after myocardial infarction cost approximately $1 billion per year.

Conclusions: Although many patients benefit from angiography and angioplasty after myocardial infarction, others probably do not. Substantial resources are at stake.

Figures

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Figure 1.
Summary odds ratios and 95% Cls for outcomes after percutaneous transluminal coronary angioplasty (PTCA) compared with other therapies.[4]

Lower odds ratios show a benefit for using the first strategy compared with the second. Only odds ratios that do not include 1 are statistically significant; this was the case for the 6-week end points for immediate PTCA compared with thrombolysis only. Outcome category 1 is death at 6 weeks, outcome category 2 is death or nonfatal infarction at 6 weeks, outcome category 3 is death at 1 year, and outcome category 4 is death or nonfatal reinfarction at 1 year. Immediate PTCA includes trials that compare immediate PTCA (primary angioplasty) with thrombolytic agents. Aggressive PTCA includes trials of immediate, early, delayed, and rescue angioplasty compared with no angioplasty. Routine means that angioplasty was done on almost all patients as a routine strategy. Elective means that PTCA was done late as an elective procedure. Adapted from Michels and Yusuf . MI = myocardial infarction.

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