Some Patients with Persistent Coronary Artery Occlusion after Acute Myocardial Infarction may Require Revascularization

Abstract

eagues. 1 This trial was designed to evaluate the efficacy of percutaneous coronary interventions (PCI) compared with medical therapy in patients with an occluded coronary artery 2-15 days after myocardial infarction. Of the 212 patients, 109 were randomized to PCI and 103 were randomized to medical therapy. The medical therapy and PCI used were state-of-the-art. The mean time to PCI was 8 days. A large percentage of patients had single-vessel disease. Results indicated there was no difference in the primary combined endpoint of cardiac death MI or ventricular tachyarrhythmias between the two treatment arms. At 6 months, angiographic patency was more frequent in the PCI arm and left ventricular ejection fraction was greater. The trial was likely underpowered for the primary endpoint analysis and cases were at relatively low risk since exclusions from the trial were left main coronary stenosis, need for CABG, and PCI not technically feasible. The Occluded Artery TrialAt the 2006 American Heart Association meeting in Chicago, Judith Hochman presented the Occluded Artery Trial (OAT). 2 This was a National Heart, Lung, and Blood Institute-supported trial. This trial was similar to the DECOPI trial, but more patients were enrolled, such as 1,082 randomized to PCI/stent plus medical therapy and 1,084 randomized to medical therapy. Patients were stable but had persistent occlusion of the infarct-related artery, 3-28 days following myocardial infarction. Most (82%) had single-vessel disease, 49% involving the right coronary artery. Primary endpoint was death, MI, or severe heart failure, and the mean follow-up was 3 years. It must be emphasized that these patients were stable myocardial infarction survivors who did not receive PCI within the first 12 h of their infarction. It must also be emphasized that the patients who received PCI/stent also received optimal medical therapy as did all patients randomized to medical therapy. Exclusions from this trial included patients with high grade left main coronary artery stenosis or high grade three-vessel disease, angina at rest, severe ischemia on stress testing, hemodynamic or electrical instability, serum creatinine greater than 2.5 mg/dL, class III or IV heart failure, or shock. As in the DECOPI trial, median time from myocardial infarction to randomization was 8 days. In this group of selected randomized patients, results showed there was no difference in the primary composite endpoint of death, reinfarction, or severe heart failure. Initial success was seen in 87% of the PCI group and 89% were still open at 1 year. In the patients randomized to medical therapy, ninety patients crossed over to revascularization, suggesting that recurrent symptoms were present. There was a trend toward more reinfarction in the PCI group than in the medical group. This may be related to the fact that patients who received PCI had more patent arteries that might reocclude compared to the smaller percentage of patent arteries in patients randomized to medical therapy. No information is availa...