RISK STRATIFICATION AFTER MYOCARDIAL-INFARCTION IN THE THROMBOLYTIC ERA

Most patients with acute myocardial infarction do not receive or are i neligible for thrombolytic therapy, and thus their prognosis is worse than that of the populations studied in the major, randomized, lytic t herapy trials. We need to devise a cost-effective strategy with which to appropriately stratify these patients. Simple, easily ascertained c linical variables that are evident soon after hospital admission can i dentify higher-risk patients, who are likely to be older and less able to adequately complete an exercise lest. in some patients, nuclear im aging tests are appropriate; low-dose dobutamine echocardiography and ambulatory ECG monitoring may also have a role, Greater use of routine cardiac catheterization (with assessment of ventricular function) mig ht be the most appropriate way to stratify patients because it may ove rcome some of the limitations of noninvasive testing, Will clearly def ine high-risk patients, and may facilitate early discharge from the ho spital. Left ventricular function and the patency of the infarct-relat ed artery will be determined, and patients with left main coronary dis ease, significant three-vessel coronary artery disease, and two-vessel coronary disease (especially with proximal left anterior descending c oronary artery involvement) will be identified. An aggressive strategy of revascularization to improve survival in appropriate patients may be employed. Greater use of routine coronary arteriography after acute myocardial infarction would inevitably lower the threshold for inappr opriate, potentially risky, and expensive further interventions. We ne ed to focus our attention on the most appropriate strategies for the m anagement of patients whose prognosis is worse than the prognosis of t hose who receive lytic therapy after acute myocardial infarction.