Reply: Stents in Non Q Wave Myocardial Infraction

• 1.The patient had NQWMI and therefore the subset of Q wave Ml was not discussed in the case report.
• 2.This patient had recurrent angina and was thus in the group of patients at high risk of reinfarction death. He was thus considered for CAG and revascularisation.

  The VANQWISH trial was associated with higher hospital mortality and MI. largely due to the 11.6% surgical mortality in the invasive group. The other important limitation of VANQWISH included marked delay in angiography (2 days) and revascularisation (8 days) in the invasive strategy. Furthermore, the use of PTCA was more frequent in the conservative group (33% Vs 22%). Patients at very high risk (those who may benefit the most from intervention) were excluded from the trial.

  The TIMI 3b and VANQWISH were performed prior to availability of stents and IIb/IIIa inhibitors and may have limited relevance to current practice.

  In FRISC 2,2457 patients with Unstable Angina or NQWMI were randomised to an early invasive versus conservative strategy. If possible, patients were also treated with low molecular weight heparin (dalteparin) for 4-5 days prior to angiography. At 1 year, patients randomised to early invasive strategy (including stents in 61%) had less death (2.2 vs 3.9 p=0.016). MI (8.6 vs 11.6. p=0.015) and revascularisation (7.5% vs 31% p < 0.001). In TACTICS. TIMI 18,2220 patients with unstable angina or non ST elevation MI were treated with aspirin, heparin, betablockers and tirofiban on admission to hospital, with subsequent randomisation to early invasive (cardiac catheterisation and revascularisation within 48 hours) or a conservative strategy (cardiac catheterisation for recurrent ischaemia). The primary end point of death. Ml or rehospilalisation for ACS at 6 months was reduced by 18% in the invasive group with greatest benefit in patients with raised Troponins. In the light of GUSTO IV ACS which also favours invasive approach, the current evidence favours an early invasive strategy in patients presenting with USA/NQWMI.

• 3.The patient of NQWMI with recurrent angina was thus taken up for CAG followed by PTCA as per the ACC/AHA guidelines mentioned.
• 4.The patient was put on diltiazem as he had normal LV function (EF 50%) and no pulmonary congestion.
• 5.The comments in the letter to the editor do not have relevance to the case under discussion. It was not the intention of the authors to discuss the management strategies of NQWMI. This was only a case report on an individual having recurrent angina after a NQWMI.