Randomized Comparison of Percutaneous Transluminal Coronary Angioplasty and Medical Therapy in Stable Survivors of Acute Myocardial Infarction With Single Vessel Disease

Abstract

Background-Percutaneous transluminal coronary angioplasty of the infarct-related artery in stable survivors of acute myocardial infarction is often performed, even in patients without any symptoms or residual ischemia. Despite the lack of randomized studies, it is widely believed that this intervention will improve the clinical outcome of these patients. Methods and Results-Three hundred patients with single vessel disease of the infarct vessel and no or minor angina pectoris in the subacute phase (1 to 6 weeks) after an acute myocardial infarction were randomized to angioplasty (nϭ149) or medical therapy (nϭ151). Primary end point was the survival free of reinfarction, (re)intervention, coronary artery bypass surgery, or readmission for severe angina pectoris at 1 year. The event-free survival at 1 year was 82% in the medical group and 90% in the angioplasty group (Pϭ0.06). This difference was mainly driven by the difference in the need for (re)interventions (20 versus 8, Pϭ0.03). At long-term follow-up (mean, 56 months), survival was 89% and 96% (Pϭ0.02). Survival free of reinfarction, (re)intervention, or coronary artery bypass surgery was 66% and 80% in the medically and interventionally treated patients, respectively (Pϭ0.05). The use of nitrates was significantly lower in the angioplasty group, both at 1 year (38% versus 67%, Pϭ0.001) and at long-term follow-up (36% versus 55%, Pϭ0.006). Conclusions-Percutaneous revascularization of the infarct-related coronary artery in stable patients with single vessel disease improves clinical outcome at long-term follow-up and reduces the use of nitrates. The results of our study should be reproduced in a confirmatory study with a larger sample size before percutaneous coronary intervention in this low-risk patient subgroup, after myocardial infarction can be recommended as routine treatment in clinical practice.

Percutaneous Coronary Intervention Versus Optimal Medical Therapy for Prevention of Spontaneous Myocardial Infarction in Subjects With Stable Ischemic Heart Disease

“…[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] For the BARI 2D trial, we included the PCI stratum of the trial only. The trials enrolled a total of 8070 patients who were followed up for a mean of 5.0 years (range, 1.5-10.2 years) with 37 548 patient-years of follow-up.…”

Angioplasty Strategies in ST-Segment–Elevation Myocardial Infarction

“…42 Whether routine delayed angioplasty (regardless of the presence of symptoms or ischemia) within days to weeks of fibrinolysis in stable patients would be beneficial was tested in 6 trials in the balloon angioplasty era. [43][44][45][46][47][48][49] In the largest of these studies, the TIMI-II trial, 3262 patients treated with recombinant tissue plasminogen activator within 4 hours of STEMI onset were randomized to coronary arteriography 18 to 48 hours after fibrinolysis with routine balloon angioplasty if the coronary anatomy was suitable or to angiography and revascularization only in patients with spontaneous or exercise-induced ischemia. The rates of death or reinfarction in the invasive and conservative groups were similar at 42 days (11.1% and 10.1%; Pϭ0.31) and 1 year (14.7% and 15.2%; Pϭ0.…”

“…43,44 Three other trials confirmed these results, [45][46][47] 48 and another showed reduced rates of readmission for severe angina and unplanned revascularization procedures with the invasive approach. 49 One reason these early trials of routine delayed angioplasty may have been negative was the enrollment of patients regardless of whether myocardial ischemia and/or viability were present. In the Danish Trial in Acute Myocardial Infarction (DANAMI) trial, 1008 patients with inducible ischemia after fibrinolysis (Ͼ99% streptokinase) for a first STEMI were randomized to conservative care or to catheterization followed by revascularization with balloon angioplasty or coronary artery bypass graft surgery when appropriate.…”

III Diretriz sobre tratamento do infarto agudo do miocárdio

“…Alguns registros já apontam para possível benefício da revascularização nos dias ou semanas iniciais após IAM 216;217 . Nos últimos anos, diferentes estudos demonstraram benefício com a revascularização tardia de pacientes estáveis pós-infarto [218][219][220] .…”

“…Essas foram as conclusões do ALKK (Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte) 219 , uma série comparativa e randomizada com o tratamento clínico, realizada na Alemanha.…”