Risk stratification after myocardial infarction: targets and tools.

The increasing use of thrombolytic therapy and coronary revascularization, either as acute therapy or early thereafter, has ushered in the "interventional era" of management of myocardial infarction (MI). This new scenario has at least two clear cut clinical implications. First, the cardiologist can intervene earlier to change the "natural history" of MI, not only to improve the immediate inhospital prognosis but also to prevent the development of those factors affecting the clinical outcome after discharge. Second, patients currently selected for predischarge evaluation are at lower risk for subsequent cardiac events. The critical management decision is with the majority of patients who have an uncomplicated MI. Two approaches may be applied to this large cohort to assess cardiac risk before hospital discharge. One method is the initial use of noninvasive tests reserving coronary angiography for patients with abnormal test results. The second approach comprises early cardiac catheterization in virtually all survivors. The routine use of angiography after MI does not appear to lead to an improved course compared to a more selective approach. Based on observation of an excellent 1-year outcome of patients in the conservative group of the large TIMI-2 and SWIFT trials, one could conclude that predischarge risk stratification by stress testing and clinical assessment has been empirically, albeit not experimentally, validated. On the other hand, if a noninvasive test proved to be highly predictive of subsequent cardiac events, the need for doing routine coronary angiography would in large part be obviated. Developing or refining such a test should take into account several caveats.(ABSTRACT TRUNCATED AT 250 WORDS)