Routine Invasive Versus Ischemia-Guided Strategy in Patients with Acute Inferior ST-Elevation Myocardial Infarction who Received Fibrinolytic Therapy: A Prospective Randomized Controlled Pilot Trial

Aims. We sought to compare a routine invasive strategy of early coronary angiography and intended revascularization, with an ischemia-guided strategy in patients with acute inferior ST-elevation myocardial infarction (STEMI) who received fibrinolytic therapy. Methods. We enrolled 60 consecutive patients with acute inferior STEMI who received fibrinolytic therapy within 6 hours. Patients were randomly assigned to either a routine invasive strategy in which coronary angiography was performed within 48 hours with intended revascularization if eligible (Group A), or an ischemia-guided strategy in which catheterization was based on the presence of myocardial ischemia and viability as demonstrated by stress myocardial perfusion imaging (Group B). Patients were prospectively followed up for 6 months. The primary endpoint was a composite of cardiac death, recurrent myocardial infarction, recurrent ischemia or stroke at 6-month follow-up. Total costs per patient were calculated over 6 months. Results. The mean age of the whole series was 52 +/- 9.8 years (15% females). The primary endpoint occurred more frequently in group A as compared to group B, however, the difference did not meet statistical significance (36.7% versus 23.3%, respectively, p >0.05). The mean cost per patient at 6-month follow-up was significantly higher in Group A as compared to that in Group B ($4953.5 +/- 3108.5 versus $2764.6 +/- 2636.7, respectively, p <0.01). Conclusions. In patients presenting with inferior STEMI who received fibrinolytic therapy, a routine invasive strategy with early coronary angiography and intended revascularization, achieved a clinical outcome similar to an ischemia-guided strategy; yet, at a significantly higher cost.