Non-Q-Wave myocardial infarction

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Opinion Statement

The treatment of non-Q-wave infarction involves the use of antithrombotic therapy (aspirin and heparin) along with appropriate antianginal medication to reduce myocardial oxygen demands and prevent coronary spasm. In certain high-risk patient subgroups (ie, those with recurrent ischemia, persistent or significant ST segment change, congestive heart failure, or hypotension with chest pain), the use of newer agents such as the platelet glycoprotein IIb/IIIa antagonists is indicated. The role of angiography appears to be changing. In the past, at least in the United States, angiography was performed on nearly all patients with non-Q-wave infarction. Now, risk stratification into high- and low-risk subgroups can be performed based on clinical criteria. In low-risk individuals, we recommend that noninvasive testing be performed before a decision is made about an invasive evaluation. In high-risk patients, it is appropriate to perform angiography and, based on the angiographic findings, to provide appropriate therapy. Although the results of the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) study suggest that if bypass surgery is required, it should not be performed acutely, we do not believe that this is necessarily correct. Therapy must be individualized based on the risk-benefit profile of acute revascularization. Furthermore, the use of percutaneous coronary intervention, particularly with the glycoprotein IIb/IIIa antagonists and stents, is expanding to include multivessel disease, even in the presence of left ventricular dysfunction. Again, we believe therapy must be individualized to include an estimate of short- and long-term risk versus benefit. In the future, however, more data from appropriately designed clinical trials will be required to establish evidence-based therapy.