Invasive versus noninvasive management of ST-elevation acute myocardial infarction: a review of clinical trials and observational studies.
Despite decades of research, it is still unclear whether patients with uncomplicated ST-segment elevation acute myocardial infarction (AMI) should be managed with an invasive or a noninvasive approach after successful thrombolysis. We reviewed randomized trials in which patients were randomized to a strategy of routine cardiac catheterization after thrombolysis (invasive) or a strategy whereby patients received cardiac catheterization only if they demonstrated reversible ischemia by noninvasive testing (noninvasive). We also reviewed observational studies that compared outcomes for patients who were admitted to hospitals with and without availability of cardiac catheterization facilities or in different geographic regions. Evidence to date suggests that invasive approach does not result in mortality or reinfarction benefits for patients with uncomplicated ST-segment elevation AMI. However, all except one of the trials performed are dated in view of recent treatment advances, and long-term outcomes for the recent trial have not been published. Several observational studies suggest that the invasive approach may improve "softer" outcomes such as quality of life and functional status. In conclusion, there is currently no evidence to support widespread use of the invasive approach among patients with uncomplicated ST-segment elevation AMI. However, trials with long-term follow-up should be repeated in the current clinical context and should include both hard and softer outcome measures.