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The Influence of Clinical Risk Factors on the Use of Angiography and Revascularization After Acute Myocardial Infarction

The Influence of Clinical Risk Factors on the Use of Angiography and Revascularization After... Abstract Background: Coronary revascularization provides the greatest survival advantage in those patients with the greatest mortality risk. This study examines the relationship between variables that predict mortality and the use of angiography and revascularization after acute myocardial infarction. Methods: Study of 4823 survivors of acute myocardial infarction, who underwent angiography between 6 hours and 5 days of admission, to determine the relationship between factors that predict mortality and the use of angiography (n=2274), angioplasty (n=692), and bypass surgery (n=469). Results: Except for recurrent angina, clinical factors that predict higher mortality were associated with a lower use of angiography (the multivariable adjusted odds ratio was 0.47 for older age, 0.85 for a history of infarction, 0.50 for patients not receiving thrombolytic medications, 0.64 for new heart failure, and 2.75 for recurrent angina [P<.001 for all factors]). A similar relationship was observed among patients selected for angioplasty (the odds ratio was 0.51 for an ejection fraction of <40%, 0.72 for those patients not receiving thrombolytic medications, 0.74 for a history of infarction, and 1.94 for recurrent angina [P<.001 for all factors]). In contrast, patients with unfavorable prognostic profiles were much more likely to undergo coronary bypass surgery (the odds ratio was 1.46 for recurrent angina, 1.28 for older age groups, 2.23 for new heart failure, 1.28 for patients not receiving thrombolytic medications, and 1.46 for a history of infarction [P<.001 for all factors]). Conclusions: These data suggest that aside from symptoms of recurrent angina, the use of angiography and angioplasty is not driven by mortality risk stratification. In contrast, bypass surgery is preferentially performed in patients at increased risk for mortality.(Arch Intern Med. 1995;155:2309-2316) References 1. Detre K, Peduzzi P, Murphy M, et al. Effect of bypass surgery on survival in patients in low- and high-risk subgroups delineated by the use of simple clinical variables. Circulation . 1981;63:1329-1337.Crossref 2. The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med . 1984;311:1333-1339.Crossref 3. Passamani E, Davis K, Gillespie M, et al. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med . 1985;312:1665-1671.Crossref 4. Peduzzi P, Hultgren H. Effect of medical vs surgical treatment on symptoms in stable angina pectoris: the Veterans Affairs cooperative study of surgery for coronary arterial occlusive disease. Circulation . 1979;60:888-899.Crossref 5. Fisch C, DeSanctis RW, Dodge HT, et al. Guidelines for coronary angiography: a report of the American College of Cardiology/American Heart Association task force on assessment of diagnostic and therapeutic cardiovascular procedures. JAm Coll Cardiol . 1987;10:869-878.Crossref 6. The Multicenter Postinfarction Research Group. Risk stratification and survival after myocardial infarction. N Engl J Med . 1983;309:331-336.Crossref 7. Taylor G, O'Neal-Humphries J, Mellits E, et al. Predictors of clinical course, coronary anatomy and left ventricular function after recovery from acute myocardial infarction. Circulation . 1980;62:960-969.Crossref 8. Arnold AE, Simoons ML, Detry JM, et al. Prediction of mortality following hospital discharge after thrombolysis for acute myocardial infarction: is there a need for coronary angiography? Eur Heart J . 1993;14:306-315.Crossref 9. Epstein SE, Palmeri ST, Patterson RE. Evaluation of patients after acute myocardial infarction: indications for cardiac catheterization and surgical intervention. N Engl J Med . 1982;307:1487-1492.Crossref 10. Stevenson R, Ranjadayalan K, Wilkinson P, Roberts RD. Short- and long-term prognosis of acute myocardial infarction since introduction of thrombolysis. BMJ . 1993;307:349-353.Crossref 11. Ross J Jr, Gilpin EA, Madssen EB, et al. A decision scheme for coronary angiography after acute myocardial infarction. Circulation . 1989;79:292-303.Crossref 12. Waters DD, Bosch X, Bouchard A, et al. Comparison of clinical variables and variables derived from a limited predischarge exercise test as predictors of early and late mortality after myocardial infarction. J Am Coll Cardiol . 1985; 5:1-8.Crossref 13. Gunnar R, Bourdillon P, Dixon D, et al. ACC/AHA guidelines for the early management of patients with acute myocardial infarction. Circulation . 1990;82: 664-707.Crossref 14. Topol E, Holmes D, Rogers W. Coronary angiography after thrombolytic therapy for acute myocardial infarction. Ann Intern Med . 1991;114:877-885.Crossref 15. Krone RJ. The role of risk stratification in the early management of a myocardial infarction. Ann Intern Med . 1992;116:223-237.Crossref 16. Williams DO, Braunwald E, Knatterud G, et al. One-year results of the Thrombolysis in Myocardial Infarction Investigation (TIMI): phase II trial. Circulation . 1992;85:533-542.Crossref 17. Weaver WD, Eisenberg MS, Martin JS, et al. Myocardial infarction triage and intervention project, phase I: patient characteristics and feasibility of prehospital initiation of thrombolytic therapy. J Am Coll Cardiol . 1990;15: 925-931.Crossref 18. DeBusk RF, Blomqvist G, Kouchoukos NT, et al. Identification and treatment of low-risk patients after acute myocardial infarction and coronary artery bypass surgery. N Engl J Med . 1986;314:161-166.Crossref 19. Nicod P, Gilpin EA, Dittrich H, et al. Trends in use of coronary angiography in subacute phase of myocardial infarction. Circulation . 1991;84:1004-1015.Crossref 20. Mueller HS, Cohen LS, Braunwald E, et al. Predictors of early morbidity and mortality after thrombolytic therapy of acute myocardial infarction: analyses of patient subgroups in the Thrombolysis in Myocardial Infarction Investigation (TIMI): phase II trial. Circulation . 1992;85:1254-1264.Crossref 21. Cragg DR, Friedman HZ, Bonema JD, et al. Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy. Ann Intern Med . 1991;115:173-177.Crossref 22. Rich MW, Bosner MS, Chung MK, Shen J, McKenzie JP. Is age an independent predictor of early and late mortality in patients with acute myocardial infarction? Am J Med . 1992;92:7-13.Crossref 23. Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two-year experience with 250 patients. Am J Cardiol . 1967;20:457-464.Crossref 24. Goldberg RJ, Gore JM, Alpert JS, et al. Cardiogenic shock after acute myocardial infarction: incidence and mortality from a community-wide perspective, 1975 to 1988. N Engl J Med . 1991;325:1117-1122.Crossref 25. Fiebach NH, Viscoli CM, Horwitz RI. Differences between women and men in survival after myocardial infarction: biology or methodology? JAMA . 1990; 263:1092-1096.Crossref 26. Goldberg RJ, Gorak EJ, Yarzebski J, et al. A communitywide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease. Circulation . 1993;87:1947-1953.Crossref 27. Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in the treatment and outcome of acute myocardial infarction: results from the myocardial infarction triage and intervention registry. Arch Intern Med . 1992;152:972-976.Crossref 28. Ayanian JZ, Epstein AM. Differences In the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med . 1991;325: 221-225.Crossref 29. Steingart RM, Packer M, Hamm P, et al. Sex differences in the management of coronary artery disease. N Engl J Med . 1991;325:226-230.Crossref 30. Bickell NA, Pieper KS, Lee KL, et al. Referral patterns for coronary artery disease treatment: gender bias or good clinical judgment? Ann Intern Med . 1992; 116:791-797.Crossref 31. Mark DB, Shaw LK, DeLong ER, Califf RM, Pryor DB. Absence of sex bias in the referral of patients for cardiac catheterization. N Engl J Med . 1994;330: 1101-1106.Crossref 32. Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med . 1993; 328:673-679.Crossref 33. Zijlstra F, Jan de Boer M, Hoorntje JC, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med . 1993;328:680-684.Crossref 34. Lange RA, Hillis LD. Immediate angioplasty for acute myocardial infarction. N Engl J Med . 1993;328:726-728.Crossref 35. The Myocardial Infarction Cost Study Group. Determinants of cost for acute myocardial infarction: a report from the myocardial infarction cost study (MCIS). JAm Coll Cardiol . 1994;1A:484A. 36. Altman DG. Practical Statistics for Medical Research . London, England: Chapman & Hall; 1991:266-268. 37. Every NR, Larson EB, Litwin PE, et al. The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. N Engl J Med . 1993;329:546-551.Crossref 38. Schlant RC, Blomqvist CG, Brandenburg RO, et al. Guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association task force on assessment of cardiovascular procedures. J Am Coll Cardiol . 1986;8:725-738.Crossref 39. Mock MB, Ringqvist I, Fisher LD, et al. Survival of medically treated patients in the coronary artery surgery study (CASS) registry. Circulation . 1982;66: 562-568.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The Influence of Clinical Risk Factors on the Use of Angiography and Revascularization After Acute Myocardial Infarction

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430210059009
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Abstract

Abstract Background: Coronary revascularization provides the greatest survival advantage in those patients with the greatest mortality risk. This study examines the relationship between variables that predict mortality and the use of angiography and revascularization after acute myocardial infarction. Methods: Study of 4823 survivors of acute myocardial infarction, who underwent angiography between 6 hours and 5 days of admission, to determine the relationship between factors that predict mortality and the use of angiography (n=2274), angioplasty (n=692), and bypass surgery (n=469). Results: Except for recurrent angina, clinical factors that predict higher mortality were associated with a lower use of angiography (the multivariable adjusted odds ratio was 0.47 for older age, 0.85 for a history of infarction, 0.50 for patients not receiving thrombolytic medications, 0.64 for new heart failure, and 2.75 for recurrent angina [P<.001 for all factors]). A similar relationship was observed among patients selected for angioplasty (the odds ratio was 0.51 for an ejection fraction of <40%, 0.72 for those patients not receiving thrombolytic medications, 0.74 for a history of infarction, and 1.94 for recurrent angina [P<.001 for all factors]). In contrast, patients with unfavorable prognostic profiles were much more likely to undergo coronary bypass surgery (the odds ratio was 1.46 for recurrent angina, 1.28 for older age groups, 2.23 for new heart failure, 1.28 for patients not receiving thrombolytic medications, and 1.46 for a history of infarction [P<.001 for all factors]). Conclusions: These data suggest that aside from symptoms of recurrent angina, the use of angiography and angioplasty is not driven by mortality risk stratification. In contrast, bypass surgery is preferentially performed in patients at increased risk for mortality.(Arch Intern Med. 1995;155:2309-2316) References 1. Detre K, Peduzzi P, Murphy M, et al. Effect of bypass surgery on survival in patients in low- and high-risk subgroups delineated by the use of simple clinical variables. Circulation . 1981;63:1329-1337.Crossref 2. The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med . 1984;311:1333-1339.Crossref 3. Passamani E, Davis K, Gillespie M, et al. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med . 1985;312:1665-1671.Crossref 4. Peduzzi P, Hultgren H. Effect of medical vs surgical treatment on symptoms in stable angina pectoris: the Veterans Affairs cooperative study of surgery for coronary arterial occlusive disease. Circulation . 1979;60:888-899.Crossref 5. Fisch C, DeSanctis RW, Dodge HT, et al. Guidelines for coronary angiography: a report of the American College of Cardiology/American Heart Association task force on assessment of diagnostic and therapeutic cardiovascular procedures. JAm Coll Cardiol . 1987;10:869-878.Crossref 6. The Multicenter Postinfarction Research Group. Risk stratification and survival after myocardial infarction. N Engl J Med . 1983;309:331-336.Crossref 7. Taylor G, O'Neal-Humphries J, Mellits E, et al. Predictors of clinical course, coronary anatomy and left ventricular function after recovery from acute myocardial infarction. Circulation . 1980;62:960-969.Crossref 8. Arnold AE, Simoons ML, Detry JM, et al. Prediction of mortality following hospital discharge after thrombolysis for acute myocardial infarction: is there a need for coronary angiography? Eur Heart J . 1993;14:306-315.Crossref 9. Epstein SE, Palmeri ST, Patterson RE. Evaluation of patients after acute myocardial infarction: indications for cardiac catheterization and surgical intervention. N Engl J Med . 1982;307:1487-1492.Crossref 10. Stevenson R, Ranjadayalan K, Wilkinson P, Roberts RD. Short- and long-term prognosis of acute myocardial infarction since introduction of thrombolysis. BMJ . 1993;307:349-353.Crossref 11. Ross J Jr, Gilpin EA, Madssen EB, et al. A decision scheme for coronary angiography after acute myocardial infarction. Circulation . 1989;79:292-303.Crossref 12. Waters DD, Bosch X, Bouchard A, et al. Comparison of clinical variables and variables derived from a limited predischarge exercise test as predictors of early and late mortality after myocardial infarction. J Am Coll Cardiol . 1985; 5:1-8.Crossref 13. Gunnar R, Bourdillon P, Dixon D, et al. ACC/AHA guidelines for the early management of patients with acute myocardial infarction. Circulation . 1990;82: 664-707.Crossref 14. Topol E, Holmes D, Rogers W. Coronary angiography after thrombolytic therapy for acute myocardial infarction. Ann Intern Med . 1991;114:877-885.Crossref 15. Krone RJ. The role of risk stratification in the early management of a myocardial infarction. Ann Intern Med . 1992;116:223-237.Crossref 16. Williams DO, Braunwald E, Knatterud G, et al. One-year results of the Thrombolysis in Myocardial Infarction Investigation (TIMI): phase II trial. Circulation . 1992;85:533-542.Crossref 17. Weaver WD, Eisenberg MS, Martin JS, et al. Myocardial infarction triage and intervention project, phase I: patient characteristics and feasibility of prehospital initiation of thrombolytic therapy. J Am Coll Cardiol . 1990;15: 925-931.Crossref 18. DeBusk RF, Blomqvist G, Kouchoukos NT, et al. Identification and treatment of low-risk patients after acute myocardial infarction and coronary artery bypass surgery. N Engl J Med . 1986;314:161-166.Crossref 19. Nicod P, Gilpin EA, Dittrich H, et al. Trends in use of coronary angiography in subacute phase of myocardial infarction. Circulation . 1991;84:1004-1015.Crossref 20. Mueller HS, Cohen LS, Braunwald E, et al. Predictors of early morbidity and mortality after thrombolytic therapy of acute myocardial infarction: analyses of patient subgroups in the Thrombolysis in Myocardial Infarction Investigation (TIMI): phase II trial. Circulation . 1992;85:1254-1264.Crossref 21. Cragg DR, Friedman HZ, Bonema JD, et al. Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy. Ann Intern Med . 1991;115:173-177.Crossref 22. Rich MW, Bosner MS, Chung MK, Shen J, McKenzie JP. Is age an independent predictor of early and late mortality in patients with acute myocardial infarction? Am J Med . 1992;92:7-13.Crossref 23. Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two-year experience with 250 patients. Am J Cardiol . 1967;20:457-464.Crossref 24. Goldberg RJ, Gore JM, Alpert JS, et al. Cardiogenic shock after acute myocardial infarction: incidence and mortality from a community-wide perspective, 1975 to 1988. N Engl J Med . 1991;325:1117-1122.Crossref 25. Fiebach NH, Viscoli CM, Horwitz RI. Differences between women and men in survival after myocardial infarction: biology or methodology? JAMA . 1990; 263:1092-1096.Crossref 26. Goldberg RJ, Gorak EJ, Yarzebski J, et al. A communitywide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease. Circulation . 1993;87:1947-1953.Crossref 27. Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in the treatment and outcome of acute myocardial infarction: results from the myocardial infarction triage and intervention registry. Arch Intern Med . 1992;152:972-976.Crossref 28. Ayanian JZ, Epstein AM. Differences In the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med . 1991;325: 221-225.Crossref 29. Steingart RM, Packer M, Hamm P, et al. Sex differences in the management of coronary artery disease. N Engl J Med . 1991;325:226-230.Crossref 30. Bickell NA, Pieper KS, Lee KL, et al. Referral patterns for coronary artery disease treatment: gender bias or good clinical judgment? Ann Intern Med . 1992; 116:791-797.Crossref 31. Mark DB, Shaw LK, DeLong ER, Califf RM, Pryor DB. Absence of sex bias in the referral of patients for cardiac catheterization. N Engl J Med . 1994;330: 1101-1106.Crossref 32. Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med . 1993; 328:673-679.Crossref 33. Zijlstra F, Jan de Boer M, Hoorntje JC, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med . 1993;328:680-684.Crossref 34. Lange RA, Hillis LD. Immediate angioplasty for acute myocardial infarction. N Engl J Med . 1993;328:726-728.Crossref 35. The Myocardial Infarction Cost Study Group. Determinants of cost for acute myocardial infarction: a report from the myocardial infarction cost study (MCIS). JAm Coll Cardiol . 1994;1A:484A. 36. Altman DG. Practical Statistics for Medical Research . London, England: Chapman & Hall; 1991:266-268. 37. Every NR, Larson EB, Litwin PE, et al. The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. N Engl J Med . 1993;329:546-551.Crossref 38. Schlant RC, Blomqvist CG, Brandenburg RO, et al. Guidelines for exercise testing: a report of the American College of Cardiology/American Heart Association task force on assessment of cardiovascular procedures. J Am Coll Cardiol . 1986;8:725-738.Crossref 39. Mock MB, Ringqvist I, Fisher LD, et al. Survival of medically treated patients in the coronary artery surgery study (CASS) registry. Circulation . 1982;66: 562-568.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 27, 1995

References