Clinical Research
Post-Infarction Myocardial Perfusion Imaging
An Initial Strategy of Intensive Medical Therapy Is Comparable to That of Coronary Revascularization for Suppression of Scintigraphic Ischemia in High-Risk But Stable Survivors of Acute Myocardial Infarction

https://doi.org/10.1016/j.jacc.2006.07.068Get rights and content
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Objectives

The purpose of this study was to determine the relative benefit of intensive medical therapy compared with coronary revascularization for suppressing scintigraphic ischemia.

Background

Although medical therapies can reduce myocardial ischemia and improve patient survival after acute myocardial infarction, the relative benefit of medical therapy versus coronary revascularization for reducing ischemia is unknown.

Methods

A prospective randomized trial in 205 stable survivors of acute myocardial infarction was made to define the relative efficacy of an intensive medical therapy strategy versus coronary revascularization for suppressing scintigraphic ischemia as assessed by serial gated adenosine Tc-99m sestamibi myocardial perfusion tomography. All patients at baseline had large total (≥20%) and ischemic (≥10%) adenosine-induced left ventricular perfusion defects and an ejection fraction ≥35%. Imaging was performed during 1 to 10 days of hospital admission and repeated in an identical fashion after optimization of therapy. Patients randomized to either strategy had similar baseline demographic and scintigraphic characteristics.

Results

Both intensive medical therapy and coronary revascularization induced significant but comparable reductions in total (−16.2 ± 10% vs. −17.8 ± 12%; p = NS) and ischemic (−15 ± 9% vs. −16.2 ± 9%; p = NS) perfusion defect sizes. Likewise, a similar percentage of patients randomized to medical therapy versus coronary revascularization had suppression of adenosine-induced ischemia (80% vs. 81%; p = NS).

Conclusions

Sequential adenosine sestamibi myocardial perfusion tomography can effectively monitor changes in scintigraphic ischemia after anti-ischemic medical or coronary revascularization therapy. A strategy of intensive medical therapy is comparable to coronary revascularization for suppressing ischemia in stable patients after acute infarction who have preserved LV function.

Abbreviations and Acronyms

ADSPECT
adenosine technetium-99m sestamibi single-photon emission computed tomography
AMI
acute myocardial infarction
BB
beta-blockers
CABG
coronary artery bypass grafting
CAD
coronary artery disease
CCB
calcium-channel blocker
EF
ejection fraction
LAD
left anterior descending
LV
left ventricular
PCI
percutaneous coronary intervention
PDS
perfusion defect size

Cited by (0)

Funding for INSPIRE was provided by Bristol-Myers Squibb Medical Imaging, Astellas Pharma US, and the Schering Plough Research Institute.

1

Dr. Mahmarian is on the Advisory Board for CV Therapeutics and Astellas Pharma US.

2

Dr. Shaw has received research grants for the END and COURAGE trials

3

Dr. Filipchuk received research grants for the DIAD, CCORD, and AMISCAN studies

4

Drs. Iskander and Henzlova are on the Speakers’ Bureau for Bristol-Myers Squibb.