Does angioplasty and stenting improve outcomes in patients presenting with a completely occluded vessel several days after an ST-elevation myocardial infarction?
Aggressive angioplasty and stenting of patients with stable angina who present several days after a completed ST-elevation myocardial infarction (STEMI) does not improve important clinical outcomes and may actually increase the long-term risk of reinfarction. (LOE = 1b)
Hochman JS, Lamas GA, Buller CE, et al, for the Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006;355:2395-2407. [PMID:17105759]
Randomized controlled trial (single-blinded)
Inpatient (any location) with outpatient follow-up
Although early intervention with thrombolytics or percutaneous coronary interventions (PCIs) is the current standard of care for patients with STEMI, some patients present late, after the infarct is completed. In this study, high-risk patients presenting with total occlusion of an infarct-related artery between 3 days and 28 days after the STEMI were randomized to receive PCI with stent placement and optimal medical therapy or medical therapy alone. "High risk" was defined as an ejection fraction of less than 50% and/or proximal occlusion of a major coronary artery with a large risk region, and optimal medical therapy included aspirin, an angiotensin-converting enzyme inhibitor, a beta-blocker, lipid lowering therapy, and anticoagulation, if indicated. A total of 2166 patients were included in the study. They had a mean age of 59 years, 78% were men, and 80% were white. The infarct-related artery was the right coronary in 49% of patients and the left anterior descending in 36%. The groups were balanced at the start of the study, analysis was by intention to treat, and outcomes were adjudicated by a monitoring committee blinded to treatment assignment. Patients were followed up for up to 5 years, with a mean follow-up of 2.9 years. At 4 years, there was a trend toward a greater likelihood of nonfatal reinfarction in the PCI group (hazard ratio [HR] = 1.44; 95% CI, 0.96 - 2.16) and for fatal and nonfatal reinfarction (HR = 1.36; 0.92 - 2.00). There was no difference in mortality and no important trends favoring PCI.
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