OUTCOMES IN PATIENTS WITH ACUTE NON-Q-WAVE MYOCARDIAL-INFARCTION RANDOMLY ASSIGNED TO AN INVASIVE AS COMPARED WITH A CONSERVATIVE MANAGEMENT STRATEGY

Background Non-Q-wave myocardial infarction is usually managed accordi ng to an ''invasive'' strategy (i.e., one of routine coronary angiogra phy followed by myocardial revascularization). Methods We randomly ass igned 920 patients to either ''invasive'' management (462 patients) or ''conservative'' management, defined as medical therapy and noninvasi ve testing, with subsequent invasive management if indicated by the de velopment of spontaneous or inducible ischemia (458 patients), within 72 hours of the onset of a non-Q-wave infarction. Death or nonfatal in farction made up the combined primary end point. Results During an ave rage follow-up of 23 months, 152 events (80 deaths and 72 nonfatal inf arctions) occurred in 138 patients who had been randomly assigned to t he invasive strategy, and 139 events (59 deaths and 80 nonfatal infarc tions) in 123 patients assigned to the conservative strategy (P=0.35). Patients assigned to the invasive strategy had worse clinical outcome s during the first year of follow-up. The number of patients with one of the components of the primary end point (death or nonfatal myocardi al infarction) and the number who died were significantly higher in th e invasive-strategy group at hospital discharge (36 vs. 15 patients, P =0.004, for the primary end point; 21 vs. 6, P=0.007, for death), at o ne month (48 vs. 26, P=0.072; 23 vs. 9, P=0.021), and at one year (111 vs. 85, P=0.05; 58 vs. 36, P=0.025). Overall mortality during follow- up did not differ significantly between patients assigned to the conse rvative-strategy group and those assigned to the invasive-strategy gro up (hazard ratio, 0.72; 95 percent confidence interval, 0.51 to 1.01). Conclusions Most patients with non-Q-wave myocardial infarction do no t benefit from routine, early invasive management consisting of corona ry angiography and revascularization. A conservative, ischemia-guided initial approach is both safe and effective. (C) 1998, Massachusetts M edical Society.