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