Drugs

, Volume 42, Supplement 2, pp 28–37 | Cite as

Management of Acute Non-Q-Wave Myocardial Infarction

The Role of Prophylactic Diltiazem Therapy and Indications for Predischarge Coronary Arteriography
  • Robert S. Gibson
Article

Summary

Non-Q-wave myocardial infarction (MI) differs from Q-wave MI in 3 important respects: a smaller infarct size, possibly due to early reperfusion resulting from spontaneous thrombolysis, relief of spasm, or both; more frequent patency of the infarct-related artery; and a larger residual mass of viable but jeopardised myocardium within the perfusion zone of the infarct-related vessel. Left ventricular function is generally better unless impaired by previous MI. After the acute phase, the prognosis is worse when residual ischaemia is present, and reinfarction rates during hospitalisation and in the subsequent year of follow-up are higher. As myocardial ischaemia is potentially reversible, its presence should be actively sought in all patients with recognised non-Q-wave MI.

On the basis of current knowledge and available data, the following guidelines for the management of non-Q-wave MI patients can be recommended: (1) diltiazem and aspirin should be administered to all patients as soon as the diagnosis is established, unless contraindications exist; (2) patients who develop early recurrent ischaemia on therapy (i.e. angina with associated ST-T-wave changes) should undergo prompt cardiac catheterisation and myocardial revascularisation; and (3) patients with entirely uncomplicated hospital histories who are asymptomatic should undergo exercise stress testing, preferably in conjunction with 201Tl perfusion scintigraphy, before hospital discharge. Only those patients with evidence of significant residual ischaemia need cardiac catheterisation and myocardial revascularisation.

Keywords

Acute Myocardial Infarction Diltiazem Reinfarction Rate Danish Study Group Norwegian Multicenter Study Group 

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References

  1. Ambrose JA, Hjemdahl-Monsen CE, Borrico S, Gorlin R, Fuster V. Angiographic demonstration of a common link between unstable angina pectoris and non-Q wave acute myocardial infarction. American Journal of Cardiology 61: 244–247, 1988PubMedCrossRefGoogle Scholar
  2. β-Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction: I. Mortality results. Journal of the American Medical Association 147: 1707–1714, 1982CrossRefGoogle Scholar
  3. Bissett JK, Matts J, Sharma B and the Program on Surgical Control for Hyperlipidemia-Study Group (Posch). Residual myocardial jeopardy in patients with Q wave and non-Q wave infarctions. British Heart Journal 58: 460–464, 1987PubMedCrossRefGoogle Scholar
  4. Boden WE, Krone RJ, Kleiger RE, Miller JP, Hager WD, et al. Diltiazem reduces long-term cardiac event rate after non-Q wave infarction: Multicenter Diltiazem Post-Infarction Trial (MDPIT). Circulation 78(Suppl. 4): 579–596, 1988Google Scholar
  5. Boden WE, Krone R, Kleiger RE, et al. Electrocardiographic subset analysis of diltiazem administration on long-term outcome after acute myocardial infarction. American Journal of Cardiology, in pressGoogle Scholar
  6. Bosch X, Theroux P, Waters DD, Pelletier GB, Roy D. Early postinfarction ischemia: clinical, angiographic and prognostic significance. Circulation 75: 988–995, 1987PubMedCrossRefGoogle Scholar
  7. Branagan JP, Walsh K, Kelly P, Collins WC, McCafferty D, et al. Effect of early treatment with nifedipine in suspected acute myocardial infarction. European Heart Journal 7: 859–865, 1986PubMedGoogle Scholar
  8. Bussmann W, Seher W, Gruengras M. Reduction of creatine kinase and creatine kinase-MB indexes of infarct size by intravenous verapamil. American Journal of Cardiology 54: 1224–1230, 1984PubMedCrossRefGoogle Scholar
  9. Cairns JA, Gent M, Singer J, Finnie KJ, Froggatt GM, et al. Aspirin sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial. New England Journal of Medicine 313: 1369–1375, 1985PubMedCrossRefGoogle Scholar
  10. Crea F, Deanfield J, Crean P, Sharom M, Davies G, et al. Effects of verapamil in preventing early postinfarction angina and reinfarction. American Journal of Cardiology 55: 900–904, 1985PubMedCrossRefGoogle Scholar
  11. Danish Study Group on Verapamil in Myocardial Infarction (DAVIT-1). Verapamil in acute myocardial infarction. European Heart Journal 5: 516–528, 1984Google Scholar
  12. Danish Study Group on Verapamil in Myocardial Infarction. Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II-DAVIT II). American Journal of Cardiology 66: 779–785, 1990CrossRefGoogle Scholar
  13. Eisenberg PR, Lee RG, Biello DR, Geltman EM, Jaffe AS. Chest pain after nontransmural infarction. The absence of remediable coronary vasospasm. American Heart Journal 110: 515–521, 1985PubMedCrossRefGoogle Scholar
  14. Erbel R, Pep T, Meinertz T, Olshausen KV, Treese N, et al. Combination of calcium channel blocker and thrombolytic therapy in acute myocardial infarction. American Heart Journal 115: 529–538, 1988PubMedCrossRefGoogle Scholar
  15. Fuster V, Badimon L, Cohen M, Ambrose JA, Badimon JJ, et al. Insights into the pathogenesis of acute ischemic syndromes. Circulation 77: 1213–1220, 1988PubMedCrossRefGoogle Scholar
  16. Gheorghiade M, Schultz L, Tiley B, Kao W, Goldstein S. Effects of propranolol in non-Q wave acute myocardial infarction in the Beta Blocker Heart Attack Trial. American Journal of Cardiology 66: 129–133, 1990PubMedCrossRefGoogle Scholar
  17. Gibson RS. Non-Q wave myocardial infarction: diagnosis, prognosis and management. Current Problems in Cardiology 13: 9–17, 1988PubMedGoogle Scholar
  18. Gibson RS. Current status of calcium-channel blocking drugs after Q wave and non-Q wave myocardial infarction. Circulation 80(Suppl. 4): 107–119, 1989Google Scholar
  19. Gibson RS. Non-Q wave myocardial infarction: prognosis, changing incidence and management. In Gersh et al. (Eds) Acute Myocardial Infarction, pp. 284–307, Elsevier Science Publishing Co. Inc., New York, 1990Google Scholar
  20. Gibson RS, Beller GA, Gheorghiade M, Nygaard TW, Watson DD, et al. The prevalence and clinical significance of residual myocardial ischemia two weeks after uncomplicated non-Q wave infarction: a prospective natural history study. Circulation 73: 1186–1198, 1986aPubMedCrossRefGoogle Scholar
  21. Gibson RS, Boden WE, Theroux P, Strauss HD, Pratt CM, et al. Diltiazem and reinfarction in patients with non-Q wave myocardial infarction. Results of a double-blind, randomized multicenter trial. New England Journal of Medicine 315: 423–429, 1986bPubMedCrossRefGoogle Scholar
  22. Gibson RS, Young PM, Boden WE, Schectman K, Roberts R. Prognostic significance and beneficial effect of diltiazem on the incidence of early recurrent ischemia after non-Q wave myocardial infarction: results from the Multicenter Diltiazem Reinfarction Study. American Journal of Cardiology 60: 203–209, 1987PubMedCrossRefGoogle Scholar
  23. Gottlieb SO, Becker LC, Weiss JL, Shapiro EP, Chandra NC, et al. Nifedipine in acute myocardial infarction. An assessment on left ventricular function, infarct size and infarct expansion. A double-blind randomised, placebo controlled trial. British Heart Journal 59: 411–418, 1988PubMedCrossRefGoogle Scholar
  24. Hansen JF, Sigurd B, Mellerngaard K, Lyngbye J. Verapamil in acute myocardial infarction. Danish Medical Bulletin 27: 105–109, 1980PubMedGoogle Scholar
  25. Hashimoto T, Kambara H, Fudo T, Hayashi M, Tamaki S, et al. Non-Q wave versus Q wave myocardial infarction: regional myocardial metabolism and blood flow assessed by positron emission tomography. Journal of the American College of Cardiology 12: 88–93, 1988PubMedCrossRefGoogle Scholar
  26. Holland Interuniversity Nifedipine/Metoprolol Trial (HINT) Research Group. Early treatment of unstable angina in the coronary care unit: a randomized, double blind, placebo controlled comparison of recurrent ischaemia in patients treated with nifedipine or metoprolol or both. British Heart Journal 56: 400–413, 1986CrossRefGoogle Scholar
  27. ISIS-1 Collaborative Group. Randomized trial of intravenous atenolol among 16027 cases of suspected acute myocardial infarction. Lancet 2: 57–65, 1986Google Scholar
  28. ISIS-2 Collaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both or neither among 17187 cases of suspected acute myocardial infarction. Lancet 2: 349–360, 1988Google Scholar
  29. Jaffe AS, Biello DR, Sobel BE, Geltman EM. Enhancement of metabolism of jeopardized myocardium by nifedipine. International Journal of Cardiology 15: 77–89, 1987PubMedCrossRefGoogle Scholar
  30. Klimt CR, Knatterud GI, Stamler J, Meier P. Persantine-aspirin reinfarction study: II. Secondary coronary prevention with persantine and aspirin. Journal of the American College of Cardiology 7: 251–269, 1986PubMedCrossRefGoogle Scholar
  31. Lewis HD, Davis JW, Archibald BG, Steinke WE, Smitherman TC, et al. Protective effect of aspirin against acute myocardial infarction and death in men with unstable angina. Results of the Veterans Administration Cooperative Study. New England Journal of Medicine 309: 396–403, 1983PubMedCrossRefGoogle Scholar
  32. Loogna E, Silvan C, Groth T, Mogensen L. Complexity of enzyme release during acute myocardial infarction in a controlled study with early nifedipine treatment. European Heart Journal 110: 114–119, 1985Google Scholar
  33. Maisel AS, Ahnve S, Gilpin E, Henning H, Goldberg AL, et al. Prognosis after extension of myocardial infarction: the role of Q wave and non-Q wave infarction. Circulation 71: 211–217, 1985PubMedCrossRefGoogle Scholar
  34. Marmor A, Sobel BE, Roberts R. Factors presaging early recurrent myocardial infarction (extension). American Journal of Cardiology 48: 603–610, 1981PubMedCrossRefGoogle Scholar
  35. MIAMI Trial Research Group. Mortality results. American Journal of Cardiology 56(Suppl. G): 15–22, 1985Google Scholar
  36. Muller JE, Morrison J, Stone PH, Rude RE, Rosner B, et al. Nifedipine therapy for patients with threatened and acute myocardial infarction: a randomized double-blind, placebo-controlled comparison. Circulation 69: 740–747, 1984PubMedCrossRefGoogle Scholar
  37. Multicenter Diltiazem Postinfarction Trial Research Group. The effect of diltiazem on mortality and reinfarction after myocardial infarction. New England Journal of Medicine 319: 385–392, 1988CrossRefGoogle Scholar
  38. Norwegian Multicenter Study Group. Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. New England Journal of Medicine 304: 801–807, 1981CrossRefGoogle Scholar
  39. Overskeid K, Abrahamsen AM, Frisvold OI, Von der Lippe G, Lund-Johansen P, et al. Letter to the Editor. New England Journal of Medicine 305: 407, 1981Google Scholar
  40. Ross J, Brandenburg RO, Dinsmore RE, Friesinger GCII, Hultgren HH, et al. Guidelines for coronary angiography. Report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Angiography). Journal of the American College of Cardiology 10: 935–950, 1987CrossRefGoogle Scholar
  41. Scheuster EH, Bulkley BH. Early postinfarction angina: ischemia at a distance and ischemia in the infarct zone. New England Journal of Medicine 305: 1101–1105, 1981CrossRefGoogle Scholar
  42. Sirnes PA, Overskeid K, Pedersen TR, Bathen J, Drivenes A, et al. Evolution of infarct size during the early use of nifedipine in patients with acute myocardial infarction: The Norwegian Nifedipine Multicenter Trial. Circulation 70: 638–644, 1984PubMedCrossRefGoogle Scholar
  43. SPRINT-I Study Group. Secondary Prevention-Reinfarction Israeli Nifedipine Trial I. A randomized intervention trial of nifedipine in patients with acute myocardial infarction. European Heart Journal 9: 354–364, 1988Google Scholar
  44. SPRINT-II Study Group. The Secondary Prevention-Reinfarction Israeli Nifedipine Trial II. Design methods and results. European Heart Journal 9(Suppl. 1): 350, 1988Google Scholar
  45. Theoroux P, Ouimet H, McCans J, Latour J, Joly P, et al. Aspirin, heparin or both to treat acute unstable angina. New England Journal of Medicine 319: 1105–1111, 1988CrossRefGoogle Scholar
  46. Theusen L, Jorgensen JR, Kvistgaard HJ, Sorensen JA, Vaeth M, et al. Effect of verapamil on enzyme release after early intravenous administration in acute infarction. European Heart Journal 5: 516–528, 1983Google Scholar
  47. TIMI Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) Phase 2 Trial. New England Journal of Medicine 320: 618–627, 1989CrossRefGoogle Scholar
  48. Walker LJE, Mackenzie G, Adgey AAJ. Effect of nifedipine on enzymatically estimated infarct size in the early phase of acute myocardial infarction. British Heart Journal 59: 403–410, 1988PubMedCrossRefGoogle Scholar
  49. Wilcox RG, Hampton JR, Banks BC, Birkhead JS, Brooksby JAS, et al. Trial of early nifedipine in acute myocardial infarction. The Trent Study. British Medical Journal 293: 1204–1208, 1986PubMedCrossRefGoogle Scholar
  50. Zannad F, Amor M, Karcher G, Maurin P, Ethevenot G, et al. Effect of diltiazem on myocardial infarct size estimated by enzyme release, serial thalium-201 single-photon emission computed tonography and radionuclide angiography. American Journal of Cardiology 61: 1172–1177, 1988PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 1991

Authors and Affiliations

  • Robert S. Gibson
    • 1
  1. 1.Division of CardiologyUniversity of Virginia Health Sciences CenterCharlottesvilleUSA

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