Pre-discharge stress echocardiography and exercise ECG for risk stratification after uncomplicated acute myocardial infarction: results of the COSTAMI-II (cost of strategies after myocardial infarction) trial

• Published in: Heart (British Cardiac Society) Vol. 91; no. 2; pp. 146 - 151
• Main Authors: Desideri, A, Fioretti, P M, Cortigiani, L, Trocino, G, Astarita, C, Gregori, D, Bax, J, Velasco, J, Celegon, L, Bigi, R, Pirelli, S, Picano, E
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and British Cardiovascular Society 01-02-2005; BMJ; BMJ Publishing Group LTD; Copyright 2005 by Heart
• Subjects: acute myocardial infarction; Adult; Aged; AMI; Biological and medical sciences; Blood pressure; CABG; Cardiac arrhythmia; Cardiology; Cardiology. Vascular system; Cardiovascular Medicine; coronary artery bypass graft; Coronary heart disease; cost of strategies after myocardial infarction; Cost-Benefit Analysis; COSTAMI-II; Costs; DANAMI; Danish trial in acute myocardial infarction; Drug dosages; Echo Dobutamine International Cooperative; Echo Persantine International Cooperative; Echocardiography, Stress - economics; Echocardiography, Stress - methods; EDIC; Electrocardiography - methods; EPIC; Europe; Exercise - physiology; Female; Heart; Heart attacks; Hospitals; Humans; Laboratories; Male; Medical imaging; Medical sciences; Middle Aged; Mortality; myocardial infarction; Myocardial Infarction - diagnostic imaging; Myocardial Infarction - economics; Myocardial Revascularization - economics; Myocardial Revascularization - standards; Myocarditis. Cardiomyopathies; Patient Discharge; Patients; percutaneous transluminal coronary angioplasty; Physiology; Prognosis; Prospective Studies; PTCA; Quality control; Quality of Life; Risk Assessment - methods; Risk Factors; risk stratification; Poland; Italy; Spain; Sonography; Physical exercise; Myocardial infarction; Costs; Echocardiography; Acute; Cardiovascular disease; Risk; Myocardial disease; Discharge; Stress; Result; Electrodiagnosis; Heart disease; Health economy; Risk factor; Electrocardiography; Exercise tolerance test; Strategy; Stratification; Public health
• ISSN: 1355-6037; 1468-201X
• DOI: 10.1136/hrt.2003.026849

Objective: To compare in a prospective, randomised, multicentre trial the relative merits of pre-discharge exercise ECG and early pharmacological stress echocardiography concerning risk stratification and costs of treating patients with uncomplicated acute myocardial infarction. Design: 262 patients from six participating centres with a recent uncomplicated myocardial infarction were randomly assigned to early (day 3–5) pharmacological stress echocardiography (n  =  132) or conventional pre-discharge (day 7–9) maximum symptom limited exercise ECG (n  =  130). Results: No complication occurred during either stress echocardiography or exercise ECG. At one year follow up there were 26 events (1 death, 5 non-fatal reinfarctions, 20 patients with unstable angina requiring hospitalisation) in patients randomly assigned to early stress echocardiography and 18 events (2 reinfarctions, 16 unstable angina requiring hospitalisation) in the group randomly assigned to exercise ECG (not significant). The negative predictive value was 92% for stress echocardiography and 88% for exercise ECG (not significant). Total costs of the two strategies were similar (not significant). Conclusion: Early pharmacological stress echocardiography and conventional pre-discharge symptom limited exercise ECG have similar clinical outcome and costs after uncomplicated infarction. Early pharmacological stress echocardiography should be considered a valid alternative even for patients with interpretable baseline ECG who can exercise.