Elsevier

The Lancet

Volume 359, Issue 9320, 25 May 2002, Pages 1805-1811
The Lancet

Articles
Early revascularisation and 1-year survival in 14-day survivors of acute myocardial infarction: a prospective cohort study

https://doi.org/10.1016/S0140-6736(02)08710-XGet rights and content

Summary

Background

Randomised trials of early revascularisation in acute coronary syndromes have yielded conflicting results with respect to effects on survival. We assessed the association between revascularisation within 14 days after the index event and 1-year mortality in individuals who survived for at least 14 days after an acute myocardial infarction.

Methods

We studied a prospective cohort of patients admitted to the coronary care units of 61 Swedish hospitals between 1995 and 1998. We obtained 1-year mortality data from the Swedish National Cause of Death Register. We assessed 21 912 individuals with first registry-recorded acute myocardial infarction, who were younger than age 80 years, and alive at day 14. Relative risk of 1-year mortality in patients who had revascularisation (n=2554) or those who did not (n=19 358) within 14 days was calculated by Cox regression analysis, adjusting for multiple covariates that affect mortality and with a propensity score that adjusted for covariates that affected the likelihood of early revascularisation.

Findings

At 1 year, unadjusted mortality was 9·0% (1751 deaths) in the conservative group and 3·3% (84 deaths) in the early revascularisation group. In the Cox regression analysis early revascularisation was associated with a reduction in 1-year mortality (relative risk 0·47; 95% Cl 0·37–0·60; p <0·001). This relative reduction of mortality was similar in all subgroups irrespective of age, sex, baseline characteristics, previous disease manifestations, or treatment.

Interpretation

Early revascularisation in individuals with acute myocardial infarction is associated with substantial reduction in 1-year mortality. Our findings lend support to the use of an invasive approach early after an acute myocardial infarction.

Introduction

Results of randomised trials on the survival benefits of early revascularisation after acute coronary syndromes are inconsistent. In the FRISC II study,1 for example, an early invasive approach was associated with a significant survival benefit, whereas in the TIMI IIIB2 and TACTICS-TIMI 183 studies, mortality was similar irrespective of whether or not revascularisation was done. Furthermore, in the VANQWISH4 trial, in men with non-ST-segment elevation myocardial infarction (NSTEMI), there was reduced survival associated with an early invasive strategy. With respect to ST-segment elevation myocardial infarction (STEMI) direct percutaneous coronary intervention in the PAMI-1 study5 resulted in improved survival, whereas no survival benefit was noted in the GUSTO IIB trial.6 Early revascularisation after fibrinolytic treatment did not greatly improve survival, neither in patients with exercise-induced ischaemia in the DANAMI7 trial nor in unselected patients after STEMI in the TIMI II,8, 9 TAMI-5,10 SWIFT,11 or other trials.12, 13, 14 Registry studies15, 16 have not shown any reduction in mortality by a more invasive approach in patients with unstable angina or NSTEMI. By contrast, results of studies have consistently indicated a reduced rate of reinfarction, which would be expected to result in a lower mortality at longer follow-up, in patients with NSTEMI1, 3 and STEMI6, 7, 17 who had an early invasive strategy compared with no early invasive strategy. Our aim was, therefore, to investigate the effect on 1-year mortality of revascularisation within 14 days after an acute myocardial infarction in a large cohort of unselected patients.

Section snippets

Study protocol

We included in our analyses data obtained from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA) between 1995 and 1998. RIKS-HIA contains details of all patients admitted to the coronary care units of participating hospitals. Information is reported on case record forms and includes 100 variables18 carefully predefined by the steering committee and accepted by the Swedish Society of Cardiology (full protocol at http://www.riks-hia.c.se, accessed

Results

42 422 individuals with acute myocardial infarctions were admitted to one of the participating coronary care units between 1995 and 1998. Of these, 36 294 patients had their first acute myocardial infarction during the registration period, and 21 912 were younger than age 80 years, survived for at least 14 days after the event, and had complete data. Table 1 shows baseline characteristics of patients. Individuals revascularised early were younger, more often men, and were less likely to have

Discussion

Our findings indicate that early invasive treatment after acute myocardial infarction improves mortality, especially in those with NSTEMI, but also in individuals with STEMI. Of the previous randomised trials1, 2, 4, 7, 9, 10, 11, 12, 13, 14, 21, 22, 23, 24 and registry studies,15, 16 these results accord only with those of the FRISC II trial1 in NSTEMI patients. Results of studies of direct percutaneous coronary intervention in STEMI5, 25 have indicated a survival benefit, but no study

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