Long-term Outcomes of Regional Variations in Intensity of Invasive vs Medical Management of Medicare Patients With Acute Myocardial Infarction

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Abstract
More than 280 000 Medicare enrollees are admitted to hospitals with acute myocardial infarction (AMI) annually.1 These patients face a high risk of short-term death: 18% die within 30 days of admission. Much of the effort to reduce this high mortality rate has focused on invasive diagnostic and therapeutic interventions. A recent quantitative review of randomized trials comparing primary angioplasty with thrombolytic therapy in ST-segment elevation myocardial infarction (STEMI) patients demonstrated long-term survival benefit in the more invasively treated group.2 Randomized trials comparing early invasive with conservative strategies in non–ST-segment elevation myocardial infarction (NSTEMI) patients demonstrated mixed survival results but improved cardiac morbidity.3-7 Evidence suggests that invasive management strategies primarily benefit elderly or high-risk patients and may not be warranted in lower-risk patients.8-11 However, in practice these interventions have been primarily directed to younger, lower-risk patients.12

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