Long-term (Three-year) prognosis of patients treated with reperfusion or conservatively after acute myocardial infarction

OBJECTIVES This survey sought to assess the frequency of the use of thrombo lytic therapy, invasive coronary procedures (ICP) (angiography, percutaneou s transluminal coronary angioplasty and coronary artery bypass grafting [CA BG]), variables associated with their use, and their impact on early (30-da y) and long-term (3-year) mortality after acute myocardial infarction (AMI) . BACKGROUND Few data are available regarding the implementation in daily pra ctice of the results of clinical trials of treatments for AMI and their imp act on early and long-term prognosis in unselected patients after AMI. METHODS A prospective community-based national survey was conducted during January-February 1994 in all 25 coronary care units operating in Israel. RESULTS Among 999 consecutive patients with an AMI (72% men; mean age 63 +/ - 12 years) acute reperfusion therapy (ART) was used in 455 patients (46%; thrombolysis in 435 patients [44%] and primary angioplasty in 20 [2%]). Its use was independently associated with anterior AMI location and hospitals with on-site angioplasty facilities, whereas advancing age, prior myocardia l infarction (MI) and prior angioplasty or CABG were independently associat ed with its lower use. The three-year mortality of patients treated with AR T was lower than in counterpart patients (22.0% vs. 31.4%, p = 0.0008), mai nly as the result of 30-day to 3-year outcome (12.4% vs. 21.1% ; hazard rat io = 0.73, 95% confidence interval [CI] 0.52 to 1.03). Independent predicto rs of long term mortality were: age, heart failure on admission or during t he hospitalization, ventricular tachycardia or fibrillation and diabetes. T he outcome of patients not treated with ART differed according to the reaso n for the exclusion, where patients with contraindications experienced the highest three-year (50%) mortality rate. After ART, coronary angiography, a ngioplasty and CABG were performed in-hospital in 28%, 12% and 5% of patien ts, respectively. Their use was independently associated with recurrent inf arction or ischemia, on-site catheterization or CABG facilities, non-Q-wave AMI and anterior infarct location. In the entire study population, and in patients with a non-Q-wave AMI, performance of ICP was associated with lowe r 30-day mortality (odds ratio [OR] = 0.53, 95% CI 0.25 to 0.98, and OR = 0 .21, 0.03 to 0.84, respectively), but not thereafter. CONCLUSIONS This survey demonstrates the extent of implementation in daily practice of ART and ICP and their impact on early and long-term prognosis i n an unselected population after AMI. (C) 1999 by the American College of C ardiology.