Veterans Affairs Non-Q-Wave Infarction Strategies In Hospital Research Articles

Stress test criteria used in the conservative arm of the frisc-ii trial underdetects surgical coronary artery disease whenapplied to patients in the vanqwish trial

ObjectivesWe sought to determine whether the stringent stress test criteria for crossover to cardiac catheterization in the conservative arm of the Fast Revascularization During Instability in Coronary Artery Disease (FRISC-II) trial subjected this strategy to a disadvantage by failing to identify patients with surgical coronary artery disease (CAD). BackgroundIn FRISC-II, an invasive strategy provided superior outcomes compared with a conservative strategy for patients with acute coronary syndromes. However, compared with the stress test criteria for crossover to catheterization in the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) trial, the FRISC-II criteria were more restrictive and did not use nuclear imaging or pharmacologic stress testing. MethodsWe analyzed the conservative arm of VANQWISH to identify the prevalence of surgical CAD in those patients who met the VANQWISH, but not FRISC-II, criteria for catheterization. ResultsOf 385 VANQWISH patients, 90 (23%) met the FRISC-II criteria for catheterization. Another 98 patients (25%) met only VANQWISH stress test criteria (60 patients by exercise and 38 by pharmacologic nuclear stress testing). Among subjects who underwent predischarge angiography, those meeting only VANQWISH stress test criteria had a high prevalence of surgical CAD (51%), comparable to patients who met FRISC-II criteria (54%, p = 0.805). ConclusionsThe overly stringent risk stratification protocol for conservative-arm patients in FRISC-II could have failed to identify almost as many patients with surgical CAD as it identified. A lower threshold for catheterization in the FRISC-II conservative patients might have improved their outcomes and therefore diminished the putative benefit of an invasive strategy.

Revisiting the culprit lesion in non–Q-wave myocardial infarction: Results from the VANQWISH trial angiographic core laboratory

ObjectivesWe sought to determine the underlying coronary anatomy and characterize the culprit lesion after non–Q-wave myocardial infarction (NQWMI). BackgroundAlthough the culprit lesion and infarct-related artery often are easily identified with coronary angiography after Q-wave MI, the culprit lesion after NQWMI has not been well characterized. Small retrospective studies have suggested that the absence of Q-waves on an electrocardiogram is due to incomplete occlusion of the infarct-related artery. MethodsCoronary angiograms from 350 patients randomized to the early invasive strategy in the Veterans Affairs Non–Q-Wave Infarction Strategies in-Hospital (VANQWISH) trial were systematically analyzed in an angiographic core laboratory. A consensus panel identified the culprit lesion and the infarct-related artery using prespecified criteria for complex lesion morphology and acute versus chronic occlusions. Severity of angiographic disease and left ventricular function also were analyzed. Patients with a single identified culprit lesion were compared with those who had multiple apparent culprits and those without an identifiable culprit lesion. ResultsA single culprit lesion was identified in only 49% of patients undergoing early angiography after NQWMI. The majority of patients either had no identifiable culprit (37%) or multiple apparent culprit lesions (14%). A single incomplete occlusion of the infarct-related artery was found in only 36% of patients, and an isolated acute occlusion of the infarct-related artery occurred in 13%. Patients without an identifiable culprit lesion had severe coronary disease (obstructive coronary artery disease [CAD] in 84%) but no complex lesion morphology. There was no difference in angiographic severity of disease comparing patients with and without identifiable culprit lesions. Patients with a single incomplete occlusion of the infarct-related artery were more likely to undergo percutaneous transluminal coronary angioplasty than other patients, whereas patients with multiple culprit lesions were more frequently treated with coronary artery bypass grafting. ConclusionsCoronary angiography early after NQWMI frequently identifies severe obstructive CAD, but a single identifiable culprit lesion was identified in <50% of patients. Multiple culprit lesions were seen in 14% of patients. An angiographic culprit lesion could not be identified in more than one-third of patients undergoing coronary angiography as part of an invasive strategy.

Current management of unstable angina: lessons from the TACTICS-TIMI 18 trial.

Patients presenting with unstable angina pectoris or non-Q-wave myocardial infarction (MI), if treated inadequately, are at a high risk of MI and subsequent mortality. The use of intravenous small molecule glycoprotein IIb/IIIa inhibitors along with standard therapeutic management options improves outcome. Since the publication of the Thrombolysis in Myocardial Ischemia IIIB, Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital (VANQWISH) and Fragmin and Fast Revascularization during InStability in Coronary artery disease II (FRISC II) studies, there is great debate about the advantages of following an early 'invasive' treatment option with coronary angiography and revascularization after initial medical therapy compared with the 'conservative' approach, where angiography is reserved for those who remain symptomatic. The Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy--Thrombolysis in Myocardial Infarction 18 (TACTICS-TIMI 18) study has helped to resolve some of the controversies since it was designed with more current medical (early and routine use of tirofiban) and revascularization (use of stents during percutaneous coronary interventions) options as part of the invasive treatment protocol. This study indicated that an early invasive strategy in risk stratified patients combined with early use of tirofiban with standard medical therapy significantly improves outcome and appears well tolerated.

Use of coronary revascularization in patients with unstable and non-ST- segment elevation acute myocardial infarction

Percutaneous coronary intervention can be safely performed in patients with acute coronary syndromes (ACS), including those with non-ST-segment elevation myocardial infarction (MI), and unstable angina. Although there remains debate about whether an aggressive strategy involving early coronary arteriography and revascularization should be routinely performed in patients who present with non-ST-segment elevation MI and unstable angina, recent clinical trials suggest that an aggressive approach should be taken in both intermediate- and high-risk patients with ACS. There have been 4 clinical trials that have compared the outcomes of patients presenting with non-ST-segment elevation MI or unstable angina who were assigned to invasive or conservative strategies. The Thrombolysis in Myocardial Infarction (TIMI) IIIB trial and the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial failed to demonstrate a reduction in death or MI in patients assigned to an invasive approach, but it did demonstrate an important reduction in the frequency of rehospitalization. However, these studies were performed before the availability of coronary stents or the use of glycoprotein IIb/IIIa inhibitors. In contrast, the Fragmin and Fast Revascularisation During Instability in Coronary Artery Disease (FRISC) II and the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS) trials demonstrated significant improvements in the rates of death or MI in patients with non-ST-segment elevation MI or unstable angina assigned to an invasive strategy. Event reductions were greatest in patients with non-ST-segment elevation MI or unstable angina at intermediate or high risk for an adverse outcome. Understanding that these subgroups comprise approximately 75% of patients presenting with non-ST-segment elevation MI or unstable angina, we believe that an invasive approach is indicated in most patients who develop non-ST-segment elevation MI or unstable angina. Regardless of the strategy used in ACS patients, lipid-lowering therapy is necessary to reduce recurrent ischemia events at the site of plaque instability and in atherosclerotic disease remote to the target lesion.

Non Q-wave myocardial infarction following thrombolytic therapy: a comparison of outcomes in patients randomized to invasive or conservative post-infarct assessment strategies in the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial

Non Q-wave myocardial infarction following thrombolytic therapy: a comparison of outcomes in patients randomized to invasive or conservative post-infarct assessment strategies in the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial

Incomplete risk stratification in the non invasive arm of the fast revascularization during instability in coronary artery disease (FRISC-II) compared to the veterans affairs non-Q-wave infarction strategies in hospital (VANQWISH) trials: A potential factor to explain the difference in trial outcomes Abhinav Goyal, Frederick F. Samaha, William E. Boden, Michael J. Wade, Stephen E. Kimmel. University of Pennsylvania School of

Incomplete risk stratification in the non invasive arm of the fast revascularization during instability in coronary artery disease (FRISC-II) compared to the veterans affairs non-Q-wave infarction strategies in hospital (VANQWISH) trials: A potential factor to explain the difference in trial outcomes Abhinav Goyal, Frederick F. Samaha, William E. Boden, Michael J. Wade, Stephen E. Kimmel. University of Pennsylvania School of

Non–Q-wave myocardial infarction following thrombolytic therapy: a comparison of outcomes in patients randomized to invasive or conservative post-infarct assessment strategies in the Veterans Affairs Non–Q-Wave Infarction Strategies In-Hospital (VANQWISH) trial

OBJECTIVESWe wished to determine the effect of post-infarct management strategy on event rates (death or recurrent nonfatal myocardial infarction [MI]) in patients who evolved non–Q-wave MI (NQMI) following thrombolytic therapy.BACKGROUNDPatients who evolve NQMI following thrombolytic therapy are often considered to be at high risk and are frequently managed with routine early invasive testing despite a lack of data supporting improved outcome.METHODSThe Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital (VANQWISH) study included 115 patients who evolved NQMI following thrombolytic therapy. We compared the event rates in patients randomized to routine early coronary angiography with those in patients randomized to a conservative strategy of noninvasive functional assessment, with angiography reserved for patients with spontaneous or induced ischemia.RESULTSDuring an average follow-up of 23 months, 19 of 58 patients (33%) randomized to the invasive management strategy died or suffered recurrent nonfatal MI, compared with 11 of 57 patients (19%) randomized to the conservative strategy (p = 0.152). Equivalent numbers of patients were subjected to revascularization (percutaneous transluminal coronary angioplasty or coronary artery bypass graft). There were more deaths in the invasive management group than in the conservative management group (11 vs. 2). Excess deaths could not be attributed to periprocedural mortality.CONCLUSIONSOverall event rates (death or recurrent nonfatal MI) are comparable with conservative and invasive strategies in patients who evolve NQMI following thrombolytic therapy. Mortality rate in patients managed conservatively is low (3.5%), and routine invasive management may be associated with an increased risk of death.

Avoidance of routine revascularization in the management of patients with non-ST-segment elevation acute coronary syndromes

A debate continues over whether a routine invasive or a conservative strategy is the best treatment approach for patients with non–ST-segment elevation acute coronary syndrome. The fundamental question underlying this debate is whether risk stratification should be an anatomy-driven or an ischemia-driven process. An early routine invasive or “drive-through” strategy, which consists of cardiac catheterization followed by percutaneous coronary intervention within 24 hours of the onset of angina, has not been shown to result in improved outcomes. In fact, investigators in the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) trial found that aggressively treated patients had significantly worse outcomes during the first year of follow-up than did those treated with a conservative strategy. In this overview, a conservative (ischemia-guided) strategy with aggressive medical therapy is recommended for patients with non–ST-segment elevation acute coronary syndrome. This conservative treatment includes intensive antiplatelet, antithrombotic, and anti-ischemic therapy combined with careful clinical assessment and provocative testing. Patients undergo catheterization and revascularization only if spontaneous angina occurs or there is objective evidence of stress-induced myocardial ischemia. In the future, it may be revealed that only patients at high risk have real benefit from early aggressive therapy, but the same approach may result in harm to patients at low risk. Tailoring therapy to the level of risk is essential to optimizing efficacy and clinical outcomes.

An ischemia-guided approach for risk stratification in patients with acute coronary syndromes

The optimal management approach for patients with non–ST-segment elevation acute coronary syndromes continues to be an issue of debate. An ischemia-guided strategy appears to be effective as an alternative to either a very conservative “wait-and-see” approach or a very aggressive routine revascularization approach. The need for another approach is supported by the lack of conclusive evidence-based results favoring an early routine invasive treatment strategy. In the Thrombolysis in Myocardial Infarction (TIMI) IIIB trial, there were no differences in the incidence of death or myocardial infarction (MI) between patients treated with an early invasive approach and those treated with a conservative approach to treatment. Significantly worse outcomes were shown in patients assigned to an early invasive strategy in the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) trial at 1-year follow-up (111 clinical events in the invasive group vs 85 in the conservative group; p = 0.05). Registry information, including that from the Organization to Assess Strategies for Ischemic Syndromes (OASIS), which included approximately 8,000 patients with unstable angina or suspected MI, has even suggested an excess hazard with a routine invasive approach. Patients with non–ST-segment elevation MI observed in the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO)-IIB and Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trials also fared better with an ischemia-guided strategy. Even the recent FRagmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) trial investigators had to be very selective relative to eliminating high-risk patients in the first week and treating with intense anti-ischemic therapy and 5–7 days of low-molecular-weight heparin therapy to show an advantage for assigned revascularization. A careful clinical evaluation with attention to early risk stratification is essential in the ischemia-guided approach. The Braunwald classification for unstable angina helps identify independent clinical predictors of a poor outcome; high risk is clearly associated with Braunwald class III and type C. Electrocardiographic and biochemical markers for myocardial necrosis (cardiac troponin T or I) are important tools for assessing the presence and degree of ischemia and associated risk for adverse outcome. Noninvasive evaluation of left ventricular ejection fraction is essential for identifying those at high risk due to impaired contractile function. When these conventional markers do not provide conclusive information, noninvasive stress testing is most helpful to further identify those at highest risk for revascularization.

Non-Q-Wave Myocardial Infarction.

The treatment of non-Q-wave infarction involves the use of antithrombotic therapy (aspirin and heparin) along with appropriate antianginal medication to reduce myocardial oxygen demands and prevent coronary spasm. In certain high-risk patient subgroups (ie, those with recurrent ischemia, persistent or significant ST segment change, congestive heart failure, or hypotension with chest pain), the use of newer agents such as the platelet glycoprotein IIb/IIIa antagonists is indicated. The role of angiography appears to be changing. In the past, at least in the United States, angiography was performed on nearly all patients with non-Q-wave infarction. Now, risk stratification into high- and low-risk subgroups can be performed based on clinical criteria. In low-risk individuals, we recommend that noninvasive testing be performed before a decision is made about an invasive evaluation. In high-risk patients, it is appropriate to perform angiography and, based on the angiographic findings, to provide appropriate therapy. Although the results of the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) study suggest that if bypass surgery is required, it should not be performed acutely, we do not believe that this is necessarily correct. Therapy must be individualized based on the risk-benefit profile of acute revascularization. Furthermore, the use of percutaneous coronary intervention, particularly with the glycoprotein IIb/IIIa antagonists and stents, is expanding to include multivessel disease, even in the presence of left ventricular dysfunction. Again, we believe therapy must be individualized to include an estimate of short- and long-term risk versus benefit. In the future, however, more data from appropriately designed clinical trials will be required to establish evidence-based therapy.

Conservative management was more effective than invasive management in acute non-Q-wave MI

Source Citation Boden WE, O'Rourke RA, Crawford MH, et al., for the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. Outcomes in patients with acute non...

Design and Baseline Characteristics of the Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital (VANQWISH) Trial

Objectives. The Veterans Affairs Non-Q-Wave Infarction Strategies In-Hospital (VANQWISH) trial was designed to compare outcomes of patients with a non–Q wave myocardial infarction (NQMI) who were randomized prospectively to an early “invasive” strategy versus an early “conservative” strategy. The primary objective was to compare early and late outcomes between the two strategies using a combined trial end point (all-cause mortality or nonfatal infarction) during at least 1 year of follow-up.Background. Because of the widely held view that survivors of NQMI are at high risk for subsequent cardiac events, management of these patients has become more aggressive during the last decade. There is a paucity of data from controlled trials to support such an approach, however.Methods. Appropriate patients with a new NQMI were randomized to an early “invasive” strategy (routine coronary angiography followed by myocardial revascularization, if feasible) versus an early “conservative” strategy (noninvasive, predischarge stress testing with planar thallium scintigraphy and radionuclide ventriculography), where the use of coronary angiography and myocardial revascularization was guided by the development of ischemia (clinical course or results of noninvasive tests, or both).Results. A total of 920 patients were randomized (mean follow-up 23 months, range 12 to 44). The mean patient age was 61 ± 10 years; 97% were male; 38% had ST segment depression at study entry; 30% had an anterior NQMI; 54% were hypertensive; 26% had diabetes requiring insulin; 43% were current smokers; 43% had a previous acute myocardial infarction; and 45% had antecedent angina within 3 weeks of the index NQMI.Conclusions. Baseline characteristics were compatible with a moderate to high risk group of patients with an NQMI.