Correspondence
Use of Coronary Angiography and Revascularization after Acute Myocardial Infarction
N Engl J Med 1997; 336:1024-1025April 3, 1997
- Article
To the Editor:
In their interesting analysis of the use of angiography and coronary revascularization in the first Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial (GUSTO-1), Pilote et al. (Oct. 17 issue)1 conclude that there is an excessive use of arteriography and revascularization after myocardial infarction in U.S. patients, many of whom do not clearly require such procedures, as well as an inappropriately low use of these procedures in higher-risk patients who are most likely to benefit from selective revascularization. These data will not surprise any sophisticated physician.
Not fully emphasized in the discussion was the remarkably high rate of use of angioplasty in patients at low risk (Killip class 1, 89 percent; no postinfarction ischemia, 67 percent; one diseased vessel or none, 53 percent). This is particularly noteworthy in that the early mortality and reinfarction rates were already quite low in the GUSTO population (3 percent and 6 percent, respectively). Figure 3 of the article by Pilote et al. indicates that in institutions without the capability of performing angioplasty, two thirds of patients will undergo angiography in the absence of evidence of ischemia. One assumes that the GUSTO sites represent the practice of cardiovascular medicine at its highest level of quality. The practice of many physicians elsewhere may be less reliant on published guidelines and randomized clinical trials.
Perhaps one potential solution to this “angiomania” would be to decrease the flow into the pipeline. The past several years have demonstrated conclusively that attention to the risk factors for coronary artery disease — specifically, lipid lowering with the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors — decreases the rates of death from coronary artery disease and nonfatal infarction, as well as revascularization. In the Scandinavian Simvastatin Survival Study, there was a 37 percent reduction in coronary revascularization procedures over a period of five years in patients with hypercholesterolemia2; in the Cholesterol and Recurrent Events (CARE) trial of patients with normolipidemia after myocardial infarction, revascularizations were decreased by 27 percent3; and the West of Scotland Coronary Prevention Study reported a 37 percent reduction in revascularization rates in pravastatin-treated patients.4 Reductions in procedure rates were prominent in women in the Scandinavian and CARE trials. The intestinal-bypass trial of the Program on the Surgical Control of the Hyperlipidemias and the pooled analysis of four pravastatin trials also demonstrated robust decreases in revascularization rates.
Would it not be better for our patients and the preservation of health care resources to apply evidence-based decision making to all patients who have had myocardial infarction? A reduction in low-density lipoprotein cholesterol, even in selected patients with normolipidemia, in conjunction with an appropriate application of guidelines for performing angiography and revascularization (e.g., in the case of inducible or clinical ischemia, left ventricular dysfunction, and older age) should be the standard approach for patients with coronary artery disease who have survived a myocardial infarction.
4 ReferencesJonathan Abrams, M.D.
University of New Mexico School of Medicine, Albuquerque, NM 87131-52711
Pilote L ,Miller DP ,Califf RM ,Rao JS ,Weaver WD ,Topol EJ . Determinants of the use of coronary angiography and revascularization after thrombolysis for acute myocardial infarction. N Engl J Med 1996;335:1198-1205
Full Text | Web of Science | Medline2
Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S)
Web of Science | Medline3
Sacks FM ,Pfeffer MA ,Moye LA , et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335:1001-1009
Full Text | Web of Science | Medline4
Shepherd J ,Cobbe SM ,Ford I , et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med 1995;333:1301-1307
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We are grateful to Dr. Abrams for emphasizing many of the issues raised by our article. We believe that the underuse of angiography in high-risk patients may be as important as its overuse in low-risk patients. We concur with his suggestion that the prevention of coronary artery disease may lead to decreased use of costly invasive cardiac procedures. However, the application by physicians of evidence-based prevention needs to be improved as much as the application of evidence-based medical therapy. Methods have to be developed to encourage physicians to apply evidence-based management at both the preventive level and the therapeutic level. Although the proliferation of health care plans in the United States and other countries may lead to improved adherence to practice guidelines, it may also lead to a vast underuse of needed procedures because of inappropriate financial incentives.
Louise Pilote, M.D., M.P.H.
Montreal General Hospital, Montreal, QC H3G 1A4, CanadaRobert M. Califf, M.D.
Duke University Medical Center, Durham, NC 27710Eric J. Topol, M.D.
Cleveland Clinic Foundation, Cleveland, OH 44195
