Medicine Versus Angiography in Thrombolytic Exclusion Trial - MATE

Description:

This multicenter, randomized controlled trial was designed to study whether early triage angiography with revascularization vs. a strategy of conservative management would improve clinical outcomes among patients with acute myocardial infarction ineligible for fibrinolytic therapy.

Hypothesis:

Triage angiography within 24 hours of symptoms with early revascularization, when indicated, would reduce recurrent ischemic events and death in patients with acute myocardial infarction who were ineligible for fibrinolytic therapy.

Study Design

Study Design:

Patients Enrolled: 201
Mean Follow Up: median 21 months
Mean Patient Age: mean 59 years
Female: 36

Patient Populations:

Patients ≥ 18 years presenting to the emergency department with an acute chest pain syndrome consistent with AMI (high clinical suspicion for AMI with or without immediate enzymatic confirmation) and who were considered ineligible for fibrinolysis because of a lack of diagnostic ECG changes, symptoms lasting longer than 6 hours or because of increased bleeding or stroke risks.

Exclusions:

Symptoms lasting for more than 24 hours or an absolute indication or contraindication to cardiac catheterization.

Primary Endpoints:

Composite of recurrent ischemic events and death.

Secondary Endpoints:

Length of stay and hospital costs.

Drug/Procedures Used:

Conservative arm: Admission to a monitored bed with continued medical therapy and noninvasive evaluation. There were no mandated noninvasive tests in the conservative arm. Criteria for crossover to a nonprotocol catheterization in the first 24 hours were persistent pain despite maximal medical therapy > 4 hours in duration, recurrent pain with ECG changes once pain free, or hemodynamic instability. Beyond the 24-hour window, subjects underwent catheterization based on ischemic events or physician preference.

Triage angiography arm: Patients were taken as soon as possible (within 24 hours of arrival) directly to the catheterization laboratory. The protocol encouraged decision making based on the angiogram and discouraged additional noninvasive testing. Subjects with an identifiable culprit lesion and suitable anatomy underwent percutaneous revascularization as decided by the operator. All cases referred for CABG had the operation performed during the index hospitalization.

Concomitant Medications:

Asprin, Heparin, iv Nitroglycerin, iv beta-blockers.

Principal Findings:

201 patients were randomized (111 to triage angiography and 90 to conservative management). In general, there were minimal differences in baseline characteristics among the two groups, although a history of ex-smoking and non-insulin dependent diabetes mellitus were more common in the conservative group. The mean time from symptom onset to study entry was 9 hours in both groups, and approximately one quarter of patients in the study presented with ST-segment elevation on the initial electrocardiogram.

Revascularization was performed in more patients in the triage angiography arm (58% vs. 37%, p=0.004). The mean time to revascularization was 27 vs. 88 hours (p=0.0001). The proportion of patients who had angiography and then underwent revascularization was similar in both groups, and angiographic findings were similar among patients undergoing angiography, irrespective of treatment group.

Individual rates of acute MI, reinfarction, and death were similar between both groups. However, there were more recurrent ischemic events (chest pain episodes both with and without electrocardiographic changes or hemodynamic instability) in the conservative arm, and the overall rate of the composite endpoint was greater in the conservative arm (34% vs. 13%, p=0.0002). There were no differences with respect to initial hospital costs or length of stay. Long-term follow-up demonstrated no significant differences in the endpoints of late revascularization, recurrent MI, or death.

Interpretation:

In this randomized trial of early angiography versus conservative management for fibrinolytic-ineligible patients with acute MI, there was no difference between the two arms in recurrent MI or death, but there was a decreased incidence of the primary endpoint of recurrent ischemia or death in the early triage angiography arm, largely driven by a reduction in recurrent ischemic events. MATE was not sufficiently powered to detect differences in “harder” clinical endpoints, but the reduction in recurrent ischemia was seen despite the relatively high revascularization rate within the conservative arm of the trial (37%).

These findings are similar to those of the ISAR-COOL study, a larger randomized trial of early versus delayed catheterization in a lower risk patient population, which demonstrated a reduction in recurrent ischemic events (and recurrent MI) among patients randomized to an early invasive management strategy.

References:

McCullough PA, O'Neill WW, Graham M, et al. A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy: Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial. Journal of the American College of Cardiology 1998;32:596-605.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Smoking

Keywords: Thrombolytic Therapy, Myocardial Infarction, Stroke, Follow-Up Studies, Decision Making, Electrocardiography, Emergency Service, Hospital, Hemodynamics, Smoking, Triage, Length of Stay, Hospital Costs, Chest Pain, Myocardial Revascularization, Fibrinolysis, Catheterization, Diabetes Mellitus, Type 1


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