Asymptomatic cardiac ischemia pilot (ACIP) study two-year follow-up : Outcomes of patients randomized to initial strategies of medical therapy versus revascularization

• Published in: Circulation (New York, N.Y.) Vol. 95; no. 8; pp. 2037 - 2043
• Main Authors: DAVIES, R. F, GOLDBERG, A. D, FORMAN, S, PEPINE, C. J, KNATTERUD, G. L, GELLER, N, SOPKO, G, PRATT, C, DEANFIELD, J, CONTI, C. R
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 15-04-1997; American Heart Association, Inc
• Subjects: Adrenergic beta-Antagonists - administration & dosage; Adrenergic beta-Antagonists - therapeutic use; Aged; Angioplasty, Balloon, Coronary; Atenolol - administration & dosage; Atenolol - therapeutic use; Biological and medical sciences; Calcium Channel Blockers - administration & dosage; Calcium Channel Blockers - therapeutic use; Cardiology. Vascular system; Cardiopulmonary Bypass; Cardiovascular Diseases - mortality; Comorbidity; Coronary heart disease; Diltiazem - administration & dosage; Diltiazem - therapeutic use; Drug Therapy, Combination; Electrocardiography, Ambulatory; Exercise Test; Female; Follow-Up Studies; Heart; Humans; Isosorbide Dinitrate - administration & dosage; Isosorbide Dinitrate - therapeutic use; Life Tables; Male; Medical sciences; Middle Aged; Myocardial Infarction - epidemiology; Myocardial Ischemia - diagnosis; Myocardial Ischemia - drug therapy; Myocardial Ischemia - epidemiology; Myocardial Ischemia - surgery; Myocardial Ischemia - therapy; Myocardial Revascularization; Nifedipine - administration & dosage; Nifedipine - therapeutic use; Pilot Projects; Prognosis; Risk Factors; Survival Analysis; Treatment Outcome; Vasodilator Agents - administration & dosage; Vasodilator Agents - therapeutic use; Antianginal agent; Human; Prognosis; Treatment efficiency; Instrumentation therapy; Cardiovascular disease; Asymptomatic; Instrumental dilatation; Coronary heart disease; Myocardial disease; Survival; Vascular disease; Chemotherapy; Treatment; Aortocoronary; Ischemia; Bypass; Follow up study; Surgery; Myocardium; Comparative study
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/01.CIR.95.8.2037

Patients with ischemia during stress testing and ambulatory ECG monitoring have an increased risk of cardiac events, but it is not known whether their prognosis is improved by more aggressive treatment with anti-ischemic drugs or revascularization.
The Asymptomatic Cardiac Ischemia Pilot study randomized 558 such patients who had coronary anatomy suitable for revascularization to three treatment strategies: angina-guided drug therapy (n=183), angina plus ischemia-guided drug therapy (n=183), or revascularization by angioplasty or bypass surgery (n=192). Two years after randomization, the total mortality was 6.6% in the angina-guided strategy, 4.4% in the ischemia-guided strategy, and 1.1% in the revascularization strategy (P<.02). The rate of death or myocardial infarction was 12.1% in the angina-guided strategy, 8.8% in the ischemia-guided strategy, and 4.7% in the revascularization strategy (P<.04). The rate of death, myocardial infarction, or recurrent cardiac hospitalization was 41.8% in the angina-guided strategy, 38.5% in the ischemia-guided strategy, and 23.1% in the revascularization strategy (P<.001). Pairwise testing revealed significant differences between the revascularization and angina-guided strategies for each comparison.
A strategy of initial revascularization appears to improve the prognosis of this population compared with angina-guided medical therapy. A larger long-term study is needed to confirm this benefit and to adequately test the potential of more aggressive drug therapy.