Improved clinical outcome after invasive management of patients with recent myocardial infarction and proven myocardial viability: primary results of a randomized controlled trial (VIAMI-trial)

Abstract

BackgroundPatients with ST-elevation myocardial infarction (STEMI) not treated with primary or rescue percutaneous coronary intervention (PCI) are at risk for recurrent ischemia, especially when viability in the infarct-area is present. Therefore, an invasive strategy with PCI of the infarct-related coronary artery in patients with viability would reduce the occurrence of a composite end point of death, reinfarction, or unstable angina (UA).MethodsPatients admitted with an (sub)acute myocardial infarction, who were not treated by primary or rescue PCI, and who were stable during the first 48 hours after the acute event, were screened for the study. Eventually, we randomly assigned 216 patients with viability (demonstrated with low-dose dobutamine echocardiography) to an invasive or a conservative strategy. In the invasive strategy stenting of the infarct-related coronary artery was intended with abciximab as adjunct treatment. Seventy-five (75) patients without viability served as registry group. The primary endpoint was the composite of death from any cause, recurrent myocardial infarction (MI) and unstable angina at one year. As secondary endpoint the need for (repeat) revascularization procedures and anginal status were recorded.ResultsThe primary combined endpoint of death, recurrent MI and unstable angina was 7.5% (8/106) in the invasive group and 17.3% (19/110) in the conservative group (Hazard ratio 0.42; 95% confidence interval [CI] 0.18-0.96; p = 0.032). During follow up revascularization-procedures were performed in 6.6% (7/106) in the invasive group and 31.8% (35/110) in the conservative group (Hazard ratio 0.18; 95% CI 0.13-0.43; p < 0.0001). A low rate of recurrent ischemia was found in the non-viable group (5.4%) in comparison to the viable-conservative group (14.5%). (Hazard-ratio 0.35; 95% CI 0.17-1.00; p = 0.051).ConclusionWe demonstrated that after acute MI (treated with thrombolysis or without reperfusion therapy) patients with viability in the infarct-area benefit from a strategy of early in-hospital stenting of the infarct-related coronary artery. This treatment results in a long-term uneventful clinical course. The study confirmed the low risk of recurrent ischemia in patients without viability.Trial registrationClinicalTrials.gov: NCT00149591.

Late percutaneous coronary intervention for an occluded infarct-related artery in patients with preserved infarct zone viability: A pooled analysis of cardiovascular magnetic resonance studies

“…Furthermore, with this sample size we were unable to analyze clinical end-points. However, recently published results of the VIAMI-trial, which included stable patients with acute MI not treated with primary or rescue PCI and with viability by dobutamine echocardiography, demonstrated that PCI after at least 48 h improved outcomes in comparison to conservative strategy [27]. Our findings suggest that the improved event-free survival observed with late PCI of an IRA in the VIAMI-trial may be the consequence of an improved LV systolic performance and size.…”

Gender, violence and resilience among Ugandan adolescents

“…The correlation between IPV exposure and lower resilience may be linked to compromised parenting ability of one or both caregivers in the context of intra-couple violence (Holt et al, 2008). This may be especially true in Uganda, as the majority of IPV is men’s perpetration of violence against women, and women also take on the majority of the caretaking responsibilities (Abramsky et al, 2012). …”

Assessment of Myocardial Viability: A Review of Current Non Invasive Imaging Techniques

“…An invasive approach in patients with a high viability score had a substantial reduction in ischemic events. the VIAMI-trial supports the concept that viability determines prognosis 17 .…”