Author + information
- Received December 12, 1994
- Revision received April 24, 1995
- Accepted April 25, 1995
- Published online September 1, 1995.
- William J. Rogers, MD, FACC*,
- Martial G. Bourassa, MD, FACC,
- Thomas C. Andrews, MD,
- Barry D. Bertolet, MD,
- Roger S. Blumenthal, MD,
- Bernard R. Chaitman, MD, FACC,
- Sandra A. Forman, MA,
- Nancy L. Geller, PhD,
- A. David Goldberg, MD, FACC,
- Gabriel B. Habib, MD, FACC,
- Roy G. Masters, MD,
- Robbin B. Moisa, MD, FACC,
- Hiltrud Mueller, MD, FACC,
- Douglas J. Pearce, MD, FACC,
- Carl J. Pepine, MD, FACC,
- George Sopko, MD,
- Richard M. Steingart, MD, FACC,
- Peter H. Stone, MD, FACC,
- Genell L. Knatterud, PhD,
- C. Richard Conti, MD, FACC and
- ACIP Investigators2
- ↵*Address for correspondence: Dr. William J. Rogers, University of Alabama Medical Center, Department of Medicine, Division of Cardiology, 334 LHR Building, Birmingham, Alabama 35294.
- ↵1Address for reprints: ACIP Clinical Coordinating Center, Maryland Medical Research Institute, 600 Wyndhurst Avenue, Baltimore, Maryland 21210.
Objectives This report discusses the outcome at 1 year in patients in the Asymptomatic Cardiac Ischemia Pilot (ACIP) study.
Background Comparative efficacy of medical therapy versus revascularization in treatment of asymptomatic ischemia is unknown. The ACIP study assessed the ability of three treatment strategies to suppress ambulatory electrocardiographic (ECG) ischemia to determine whether a large-scale trial studying the impact of these strategies on clinical outcomes was feasible.
Methods Five hundred fifty-eight patients with coronary anatomy amenable to revascularization, at least one episode of asymptomatic ischemia on the 48-h ambulatory ECG and ischemia on treadmill exercise testing were randomized to one of three treatment strategies: 1) medication to suppress angina (angina-guided strategy, n = 183); 2) medication to suppress both angina and ambulatory ECG ischemia (ischemia-guided strategy, n = 183); or 3) revascularization strategy (angioplasty or bypass surgery, n = 192). Medication was titrated atenolol-nifedipine or diltiazemisosorbide dinitrate.
Results The revascularization group received less medication and had less ischemia on serial ambulatory ECG recordings and exercise testing than those assigned to the medical strategies. The ischemia-guided group received more medication but had suppression of ischemia similar to the angina-guided group. At 1 year, the mortality rate was 4.4% in the angina-guided group (8 of 183), 1.6% in the ischemia-guided group (3 of 183) and 0% in the revascularization group (overall, p = 0.004; angina-guided vs. revascularization, p = 0.003; other pairwise comparisons, p = NS). Frequency of myocardial infarction, unstable angina, stroke and congestive heart failure was not significantly different among the three strategies. The revascularization group had significantly fewer hospital admissions and nonprotocol revascularizations at 1 year. The incidence of death, myocardial infarction, nonprotocol revascularization or hospital admissions at 1 year was 32% with the angina-guided medical strategy, 31% with the ischemia-guided medical strategy and 18% with the revascularization strategy (p = 0.003).
Conclusions After 1 year, revascularization was superior to both angina-guided and ischemia-guided medical strategies in suppressing asymptomatic ischemia and was associated with better outcome. These findings require confirmation by a larger scale trial.
This study was funded by the National Heart, Lung. and Blood Institute, Cardiac Disease Branch, Division of Heart and Vascular Diseases, National Institutes of Health, Bethesda, Maryland by research contracts HV-90-07, HV-90-08, HV-91-05 to HV-91-14. Study medications and placebo were donated by ICI Pharmaceuticals Group (Zeneca Pharma Inc. after April 1993), Wilmington, Delaware: MarionMerrell Dow, Kansas City, Missouri; and Pfizer, New York, New York. Support for electrocardiographic data collection was provided in part by Applied Cardiac Systems, Laguna Hills, California; Marquette Electronics, Milwaukee. Wisconsin: and Quinton Instruments, Seattle, Washington. Some units had partial support from General Clinical Research Center grants, National Institutes of Health, Bethesda, Maryland. A list of participating centers and investigators appears in the Appendix.
* See Correction on page 842.
- Received December 12, 1994.
- Revision received April 24, 1995.
- Accepted April 25, 1995.
- American College of Cardiology