Determining prognosis after acute myocardial infarction in the thrombolytic era

Non-invasive investigations still have a place

The most appropriate and cost effective approach to assessing prognosis in patients who survive an acute myocardial infarction in the thrombolytic era remains controversial. Prognosis is determined mainly by the degree of left ventricular dysfunction and the extent of residual jeopardised myocardium, both generally and in the distribution of the infarct related artery. The extent of myocardial damage and inducible ischaemia can be assessed with non-invasive stress imaging and the extent of coronary artery disease with angiography. The issue is whether “routine” coronary angiography performed soon after infarction in patients reperfused early and with an uncomplicated course yields better prognostic information than exercise or pharmacological stress perfusion imaging.

Outcome studies in America and Canada have yielded unexpected findings about the value of routine invasive investigations in patients with uncomplicated courses. Rouleau et al reported that, although coronary angiography was more often performed in America than in Canada (68% v 35%), as was revascularisation after infarction (31% v 12%), no difference in mortality (23 v 22%) or rate of reinfarction (13% v 14%) was observed at a mean follow up of 42 months.1 In …