Medical and surgical management of early Q wave myocardial infarction. II. Effects on mortality and global and regional left ventricular function at 10 or more years of follow-up

Abstract

To determine the long-term effect of surgical reperfusion on survival and left ventricular function of patients with anterior and inferior Q wave myocardial infarction, 387 patients were followed up for ≥10 years after early Q wave infarction. In the anterior infarction group, 102 received conventional therapy and 101 underwent surgical reperfusion. The overall hospital mortality rate in the medically and surgically treated patients was different (16.7% [17 of 102] versus 6.9% [7 of 101], p < 0.05). The cumulative 13 year actuarial mortality rate widened between the anterior medical and surgical groups (54% versus 31%, p = 0.0003) by the adjusted Cox proportional hazards model. The hospital mortality rate with early reperfusion (that is, ≤6 h of symptom onset) was 2% (1 of 51), whereas the mortality rate with late reperfusion was 12% (6 of 50). The 13 year actuarial cumulative mortality rate was significantly lower in both the early and late reperfusion groups (30% and 33%, respectively) than in the conventional therapy group (54%, p = 0.0006). The mortality rate in patients receiving surgery after surviving initial medical therapy was 50% (15 of 30).In the survivors of anterior Q wave myocardial infarction, improved globalejection fraction was seen in the patients undergoing early (54 ± 13%) and late (50 ± 10%) surgery relative to those receiving conventional therapy (43 ± 11%, p < 0.05). Only the early reperfusion group had better regional function of the anterior wall than that of the conventional therapy group. Thus, ventricular function correlated with improved long-term survival.In the patients with inferior Q wave myocardial infarction, the overall hospital mortality rate in the medical and surgical groups was not different (6.1% [6 of 98] versus 4.6% [6 of 86], p = NS). Likewise, the 13 year actuarial cumulative mortality rate was not different between the medical and surgical groups overall (32% versus 30%, p = 0.29) by the adjusted Cox proportional hazards model. The hospital mortality rate in the early reperfusion group was lower than that in the late reperfusion group (2.0% [1 of 49] versus 8.1% [3 of 37], p = NS). The 13 year actuarial cumulative mortality rate was lower in the early surgical group compared with that in the medical group (19% versus 32%, p = 0.04). The late surgical group had a similar 13 year actuarial cumulative mortality rate to that of the medical group (47% versus 32%, respectively, p = 0.47). The mortality rate in patients receiving surgery after surviving initial medical therapy was low (3.3%, 1 of 30). Improved regional and global ejection fraction was seen in the patients undergoing early (56 ± 9%) but not late (51 ± 11 %) reperfusion relative to values in patients receiving conventional therapy (47 ± 10%, p = NS). Early but not late reperfusion resulted in better long-term survival and better left ventricular function than did conventional therapy.