A Decision SchemeforCoronary Angiography After AcuteMyocardial Infarction

Itisimportant toselect patients intheconvalescent phase ofacute myocardial infarction inwhom knowledge ofcoronaryanatomy may identify those potentially suitable forintervention aimedat improving prognosis. However, differing guidelines havebeenproposed, andbyapplying someof these guidelines toour large database ofpatients after acutemyocardial infarction, several problem areaswere identified. Theseinclude lackofconsidering patients withresting ischemia beyond day 5ofhospitalization, management ofpatients withreduced ventricular function or patients notexercise tested, andtheroleofcoronaryangiography intheelderly. Basedon this experience andfurther analyses in1,848 patients survivingbeyond day5 ofhospitalization, a modified decision schemeforcoronaryangiography was developed andthentested ina second population (n=780). Inthenew scheme, patients over75yearsofageareconsidered individually. Thoseunder75yearsofagewithsevereresting ischemia inthehospital atanytimebeyond the first 24hours(18%mortality between day6andyear1),andhospital survivors withahistory of previousmyocardial infarction andclinical orradiographic signs ofleft ventricular failure inthe hospital (25%1-yearmortality after discharge), arerecommended forcoronaryangiography. Amongtheremaining patients, some will perform an exercise test, andthose withan ischemic responseor poorworkload (11%1-yearmortality) arealsoassigned tocoronaryangiography. Whenanexercise test isnotperformed, aresting radionuclide left ventricular ejection fraction is recommended, andcoronaryangiography isconsidered ifthevalue lies between 0.20and0.44 (12%1-yearmortality). Thisrelatively simple scheme doesnotmakegeneral recommendations in theelderly, considers patients within-hospital left ventricular failure orreduced left ventricular function orboth, andapproaches theproblem ofpatients whodonotperform an exercise test. Thisgeneral approach wouldavoid early coronaryangiography inpatients with an average1-year mortality risk after discharge of3% andrecommend coronaryangiography inthose atincreased risk(average mortality rate, 16%)whomakeupabout55%ofthis population under75yearsof age.(Circulation 1989;79:292-303)