Vanqwish Trial

The VANQWISH trial (34,35) was designed to compare outcomes of patients with a non-Q wave MI who were randomized prospectively to an early invasive strategy vs an early conservative strategy. The primary end point of the trial was all-cause mortality or nonfatal infarction during at least 1 yr of follow-up. A total of 920 patients (mean age 61 ± 10 yr) were randomized and followed for a mean duration of 23 mo (range = 12-44 mo). In the invasive arm, 462 patients underwent early coronary angiography within 3-7 d of randomization. Angioplasty was performed in patients with single-vessel disease, whereas CABG was performed for patients multivessel disease. Patients assigned to the conservative strategy (n = 458) underwent coronary angiography only

Fig. 2. Relative rates of death or MI in the early conservative and early invasive strategies in TIMI IIIB trial. Reproduced with permission from Anderson et al. One year results of the thrombolysis in myocardial infarction (TIMI) IIIB clinical trial. J Am Coll Cardiol 1995;26:1643-1650.

if they had postinfarct angina, >2 mm ST depression on exercise stress test, and >2 distribution area defects or increased lung uptake on thallium stress test. All patients received aspirin and diltiazem. Nitrates, angiotensin-converting enzymes (ACEs) inhibitors, b-blockers, heparin and thrombolytics were permitted.

After a mean follow-up of 23 mo, 96% of patients in the invasive arm and 48% in the conservative arm had undergone coronary angiography, and 44 and 33% underwent revascularization respectively. A total of 152 primary end point events (26.9% of patients) occurred in the invasive arm compared to 138 events (29.9% of patients) in the conservative arm (p = 0.35, Fig. 3). However, during the first yr, there was a significantly higher incidence of both the primary end point and death in the invasive arm (111 vs 85 events, p = 0.05 for the primary end point, and 58 vs 36, p = 0.024 for death) (Fig. 4). This difference was largely related to excess in-hospital mortality (21 vs 6 patients, p = 0.007). Further analysis revealed that 11 of 21 deaths occurred after CABG, and no deaths were reported after angioplasty.

Important limitations of this trial include marked delays in angiography (2 d) and revascularization (8 d) in the invasive group. In addition, angioplasty or CABG was performed in only 44% of patients in the invasive group, and the use of angioplasty was actually more frequent in the conservative group (33 vs 22%). Finally, patients included in the VANQWISH trial were labeled as "moderate risk." High-risk patients that would benefit mostly from an early invasive approach, such as those with postinfarct angina, congestive heart failure or persistent left bundle-branch block, were excluded from the study.

Despite those limitations, the investigators of this study concluded that patients with non-Q wave MI do not benefit from routine, early invasive management consisting of coronary angiography and revascularization, and that a conservative, ischemia-guided initial approach is both safe and effective.

Fig. 3. Probability of even-free survival in both treatment groups in the VANQWUISH trial during 12-44 mo of follow-up. Reproduced with permission from Boden et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial investigators. N Engl J Med 1998;338:1785-1792.

Fig. 4. Probability of survival in both treatment groups in the VANQWUISH trial during 12-44 mo of follow-up. Reproduced with permission from Boden et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial investigators. N Engl J Med 1998;338:1785-1792.

Fig. 4. Probability of survival in both treatment groups in the VANQWUISH trial during 12-44 mo of follow-up. Reproduced with permission from Boden et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial investigators. N Engl J Med 1998;338:1785-1792.

Fig. 5. Freedom from recurrent MI or death in both treatment groups in MATE trial over a median follow-up of 21 mo. Reproduced with permission from McCullough et al. A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Results of the medicine versus angiography in thrombolytic exclusion trial (MATE) trial. J Am Coll Cardiol 1998;32:596-605.

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