Non-Q wave myocardial infarction management strategies

In this issue, Heggunje and colleagues dissect out from the VANQWISH Trial patients with non-Q wave myocardial infarction who had a prior myocardial infarction and compare outcomes to those who did not have a prior myocardial infarction. They evaluated the trial primary end-point of death or myocardial infarction at 1 and 12 months as well as the initial randomized treatment strategy. The bottom line conclusions of their investigation indicate that a prior myocardial infarction identifies a moderately high risk subset of non-Q wave myocardial infarction patients whose outcomes are similar regardless of whether they were randomized to an invasive or non-invasive treatment strategy. Patients who did not have a previous myocardial infarction and are experiencing their first non-Q wave myocardial infarction seem to fare better with a conservative or ischaemia-guided approach during the first post-infarction year. Several points must be considered when trying to make clinical decisions about management of patients with non-Q wave myocardial infarction. Firstly, one must recognize that patients with non-Q wave myocardial infarction are not a homogeneous population. Coronary pathology can vary from single vessel coronary disease, e.g. 70% stenosis of the posterior descending coronary artery to multivessel disease with high grade stenoses in all vessels. Ventricular function may also vary from normal to abnormal. ECG changes can be extensive or minimal. Some patients will have indicators of inflammation (C-reactive protein), some will release creatine kinase, troponin I, and others will have no evidence of inflammation, release only troponin I and have normal creatine kinase serum levels. Current data available in the literature suggests that those who have these markers of inflammation and necrosis fare less well than those who do not. The type of coronary pathology in these patients also plays a role in decision making about which therapy is best for the individual patient. All who