CARDIOVASCULAR MEDICINE

Pre-discharge stress echocardiography and exercise ECG for risk stratification after uncomplicated acute myocardial infarction: results of the COSTAMI-II (cost of strategies after myocardial infarction) trial

A Desideri¹, P M Fioretti², L Cortigiani³, G Trocino⁴, C Astarita⁵, D Gregori², J Bax⁶, J Velasco⁷, L Celegon¹, R Bigi¹, S Pirelli⁸, E Picano⁹

¹ Cardiovascular Research Foundation, S Giacomo Hospital, Castelfranco Veneto, Italy
² IRCAB Foundation, S Maria della Misericordia Hospital, Udine, Italy
³ Cardiology Department, Campo di Marte Hospital, Lucca, Italy
⁴ Cardiology Department, S Gerardo Hospital, Monza, Italy
⁵ Cardiology Department, Sorrento General Hospital, Sorrento, Italy
⁶ University Medical Centre, Leiden, the Netherlands
⁷ Cardiology Department, University General Hospital, Valencia, Spain
⁸ Cardiology Department, General Hospital, Cremona, Italy
⁹ CNR Institute of Clinical Physiology, Pisa, Italy

Correspondence to:
Correspondence to:
Dr Alessandro Desideri
Cardiovascular Research Foundation, S Giacomo Hospital, 31033 Castelfranco Veneto, Italy; aldesi{at}tin.it

Objective: To compare in a prospective, randomised, multicentre trial the relative merits of pre-discharge exercise ECG and early pharmacological stress echocardiography concerning risk stratification and costs of treating patients with uncomplicated acute myocardial infarction.

Design: 262 patients from six participating centres with a recent uncomplicated myocardial infarction were randomly assigned to early (day 3–5) pharmacological stress echocardiography (n = 132) or conventional pre-discharge (day 7–9) maximum symptom limited exercise ECG (n = 130).

Results: No complication occurred during either stress echocardiography or exercise ECG. At one year follow up there were 26 events (1 death, 5 non-fatal reinfarctions, 20 patients with unstable angina requiring hospitalisation) in patients randomly assigned to early stress echocardiography and 18 events (2 reinfarctions, 16 unstable angina requiring hospitalisation) in the group randomly assigned to exercise ECG (not significant). The negative predictive value was 92% for stress echocardiography and 88% for exercise ECG (not significant). Total costs of the two strategies were similar (not significant).

Conclusion: Early pharmacological stress echocardiography and conventional pre-discharge symptom limited exercise ECG have similar clinical outcome and costs after uncomplicated infarction. Early pharmacological stress echocardiography should be considered a valid alternative even for patients with interpretable baseline ECG who can exercise.

Abbreviations: AMI, acute myocardial infarction; CABG, coronary artery bypass graft; COSTAMI-II, cost of strategies after myocardial infarction; DANAMI, Danish trial in acute myocardial infarction; EDIC, Echo Dobutamine International Cooperative; EPIC, Echo Persantine International Cooperative; PTCA, percutaneous transluminal coronary angioplasty

Keywords: myocardial infarction; risk stratification; cost–benefit analysis

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