In-hospital and late results of coronary stents versus conventional balloon angioplasty in acute myocardial infarction (GRAMI trial). Gianturco-Roubin in Acute Myocardial Infarction

Study on Correlation between Type 2 Diabetes and No-Reflow after PCI

Diabetes, a serious chronic disease globally, is often complicated with cardiovascular diseases for which percutaneous coronary intervention (PCI) is the mainstay. The no-reflow rate of diabetic patients after PCI is 2-4 times higher than that of nondiabetic patients, yet the specific mechanism is still unclear. This study was designed to investigate the correlation between the duration of diabetes, preoperative blood glucose level, coronary angiographic blood flow, coronary artery stenosis level, and no-reflow after PCI. A total of 131 patients with type 2 diabetes who underwent PCI in our hospital from 2019 to 2020 were divided into control group and observation group. The disease duration, preoperative blood glucose level, coronary angiographic blood flow, and coronary artery stenosis level of the two groups were calculated. There were differences in the duration of diabetes between the two groups; the blood glucose level of the control group was about 3.8%, which was lower than 5.8% of the observation group; the thrombolysis in myocardial infarction (TIMI) value of the control group was $18.46\pm 4.6$ , which was lower than $20.67\pm 3.9$ of the observation group; The degree of coronary stenosis in the control was $63\%\pm 2\%$ , which was lower than $76\%+3\%$ in the observation group. Binary logistic stepwise regression analysis was performed on these indicators and no-reflow after PCI to explore the correlation between these indicators and no-reflow after PCI in diabetic patients. The study found that the diabetes duration, higher preoperative blood glucose level, coronary angiography blood flow, and coronary artery were positively associated with no-reflow after PCI.

The History of Primary Angioplasty and Stenting for Acute Myocardial Infarction

The evolution of the management of acute myocardial infarction (MI) has been one of the crowning achievements of modern medicine. At the turn of the twentieth century, MI was an often-fatal condition. Prolonged bed rest served as the principal treatment modality. Over the past century, insights into the pathophysiology of MI revolutionized approaches to management, with the sequential use of surgical coronary artery revascularization, thrombolytic therapy, and percutaneous coronary intervention (PCI) with primary coronary angioplasty, and placement of intracoronary stents. The benefits of prompt revascularization inspired systems of care to provide rapid access to PCI. This review provides a historical context for our current approach to primary PCI for acute MI.

Percutaneous Mechanical Reperfusion During Acute Myocardial Infarction

The treatment of acute myocardial infarction has progressed from bedrest to mechanical, catheter-based reperfusion. The authors review the use of percutaneous coronary intervention (PCI) as a primary treatment for acute myocardial infarction and the use of adjunctive agents. The most recent American College of Cardiology/ American Heart Association (ACC/AHA) guidelines for the use of PCI in ST segment elevation myocardial infarction (MI) advocate the use of PCI as primary therapy at those centers in which the procedure can be performed within accepted standards. Because a majority of hospitals (80%) do not have the capability of performing primary PCI, most patients are treated with thrombolytic therapy. PCI should be considered in those patients treated with thrombolytic therapy who have persistent or recurrent ischemia and/or cardiogenic shock. For patients with non-ST elevation MI, the use of an invasive strategy (early angiography and PCI if needed) has recently shown to be beneficial. Although revascularization is the basis of the acute therapy of MI, additional pharmacologic therapy in the acute setting is now recognized as a key to favorable long-term outcome.

Very late hazard with stenting versus balloon angioplasty for ST-elevation myocardial infarction: a 16-year single-center experience

OBJECTIVES

This study compares very late outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI) with stenting versus balloon angioplasty (BA).

BACKGROUND

Stenting compared with BA for STEMI improves outcomes at 6-12 months, but comparisons beyond 6-12 months have not been studied. Recent studies have shown that stent thrombosis (ST) continues to increase beyond 3-5 years and may be higher with drug-eluting stents (DES) than bare metal stents (BMS). We hypothesized that there may be a very late hazard with stenting versus BA due to very late ST.

METHODS

From 1994 to 2010 consecutive patients with STEMI treated with BA (n = 601) or stenting (n = 1,594) were prospectively enrolled in our registry and followed for 1-16 years.

RESULTS

Patients treated with BA were older, were more often female, had more three-vessel disease, and had smaller vessels. Stented patients had trends for less stent/lesion thrombosis (ST/LT) and target vessel (TV) reinfarction at 1 year. In landmark analyses >1 year, stented patients had more very late ST/LT (6.1% vs. 2.9%, P = 0.002) and more TV reinfarction (7.9% vs. 3.1%, P < 0.001) which remained significant after adjusting for baseline risk. The greatest differences in very late outcomes were between DES and BA, but there were also significant differences between BMS and BA.

CONCLUSIONS

There appears to be a very late hazard with stenting versus BA for STEMI. These data should encourage new strategies for prevention of very late ST with both BMS and DES including the development of bio-absorbable polymers and stent platforms.

The incidence and clinical predictors of early stent thrombosis in patients with acute coronary syndrome

BACKGROUND

Acute coronary syndrome (ACS) is associated with activation of platelets and the coagulation system which could influence the incidence of early stent thrombosis (EST). We aimed to determine the incidence and predictors of EST in patients undergoing coronary stenting during ACS.

METHODS

The study comprised 1202 consecutive patients, drawn from a nationwide ACS survey, who underwent coronary stenting during ACS and were followed up for 30 days. Early stent thrombosis was based on the Academic Research Consortium definition.

RESULTS

Thirty patients (2.5%) sustained EST. The occurrence of EST in patients with unstable angina/non-ST-elevation myocardial infarction and ST-elevation myocardial infarction (STEMI) was 0.9% and 3.9%, respectively (P < .05), and was even higher (5.2%) in STEMI patients who underwent primary percutaneous coronary intervention. On multivariate analysis, STEMI (OR 6.3, 95% CI 2.1-18, P = .0008), multivessel disease (OR 5.9, 95% CI 1.9-21, P = .003) and Killip class >/=2 (OR 2.9, 95% CI 1.3-6.6, P = .008) were independent correlates of EST. The use of bare versus drug-eluting stents was not associated with any significant difference in EST.

CONCLUSIONS

Patients presenting with STEMI who are hemodynamically unstable and have multivessel coronary disease undergoing coronary stenting during ACS, are at increased risk of EST.

Routine stenting vs. balloon angioplasty in ST-segment elevation myocardial infarction due to proximal left anterior descending coronary artery occlusion

BACKGROUND

Primary angioplasty has been shown to improve the outcome in selected patients with ST-segment elevation myocardial infarction. However, no data have been reported of patients with proximal left anterior descending artery occlusion. In the Zwolle-6 randomized trial, a total of 1683 consecutive patients with ST-segment elevation myocardial infarction were randomized to stenting or balloon angioplasty without any exclusion criteria. The aim of this substudy was to investigate the benefits of coronary stenting as compared to balloon angioplasty in patients with proximal left anterior descending artery occlusion.

METHODS

From April 1997 to October 2001, among a total of 1683 consecutive patients with ST-segment elevation myocardial infarction randomized to stenting or balloon angioplasty before the initial angiography, a total of 218 patients underwent primary angioplasty of proximal left anterior descending artery occlusion. One-year follow-up data were available from all patients.

RESULTS

A total of 107 patients were randomized to stent and 111 patients to balloon angioplasty. The cross-over rates from balloon to stent and stent to balloon were 35.1 and 13.1%, respectively (P<0.0001). The groups were comparable in terms of postprocedural thrombolysis in myocardial infarction flow, myocardial blush grade, distal embolization, and ST-segment resolution. Stenting was associated with benefits in terms of restenosis (27.6 vs. 53.8%, P=0.03) and target vessel revascularization (15.0 vs. 24.3%, P=0.081), whereas no difference was observed in mortality (11.2 vs. 13.5%, P>0.1) and reinfarction (11.2 vs. 8.1%, P>0.1) as compared with balloon angioplasty.

CONCLUSION

As compared with balloon angioplasty, routine stenting does reduce angiographic restenosis, without significant benefits in terms of death and reinfarction among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction due to proximal left anterior descending artery occlusion.

Comparison of six-month outcomes for primary percutaneous revascularization for acute myocardial infarction with drug-eluting versus bare metal stents (from the APEX-AMI study)

We evaluated the use and outcomes of drug-eluting stents (DESs) and bare metal stents (BMSs) in a large primary percutaneous coronary intervention (PCI) acute ST-elevation myocardial infarction (MI) trial. Recently concerns have been raised with "off-label" use of DESs for short- and long-term clinical outcomes. Limited randomized data exist evaluating DESs versus BMSs in ST-elevation MI. Patients (n=5,745) in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial were categorized by stent type used. Baseline variables and clinical outcomes were collected at 90 days and 6 months. Outcomes by stent type were adjusted for using conventional multivariable predictors of 90-day mortality (age, anterior location, total ST-segment deviation, and Killip class), time to PCI, and Thrombolysis In Myocardial Infarction grade flow. Stents were deployed (at the investigator's discretion) in 5,124 patients (89.2%) with acute MI, with DES use in 2,221 (43.3%) and BMS use in 2,903 (56.7%). Patients receiving DESs were younger (median 59 vs 63 years of age, p<0.001), had left anterior descending coronary artery PCI (57.9% vs 48.1%, p<0.001), and often were treated in the United States (58.2%). DES-treated patients had a lower adjusted mortality at 90 days (hazard ratio 0.73, 95% confidence interval [CI] 0.54 to 0.99, p=0.046) and trended toward lower mortality (hazard ratio 0.77, 95% CI 0.58 to 1.03, p=0.084) and recurrent MI (hazard ratio 0.81, 95% CI 0.59 to 1.11, p=0.186) at 6 months compared with BMSs. In conclusion, in this observational analysis of stent use from a large primary percutaneous intervention for acute MI trial, DESs appear as safe as BMSs with similar 6-month clinical outcomes with regard to death and recurrent MI.

Coronary stenting versus balloon angioplasty for acute myocardial infarction: a meta-regression analysis of randomized trials

INTRODUCTION

Although stenting has been shown to reduce the need for target vessel revascularization (TVR) in acute myocardial infarction (AMI), the benefits in terms of mortality and reinfarction are still unclear. Previous meta-analyses have failed to include all currently available randomized trials. The aim of the current study was to perform an updated meta-analysis to evaluate the benefits of coronary stenting for AMI in terms of mortality, reinfarction, and TVR, and whether these benefits correlated with the patient's risk profile.

METHODS

The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) from January 1990 to September 2006. We examined all completed, published, randomized trials of coronary stenting for AMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, rescue angioplasty, stenting, and balloon angioplasty. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus.

RESULTS

A total of 13 randomized trials were identified and analyzed involving 6922 patients (3460 or 50% randomized to stent and 3462 or 50% to balloon). Stenting was not associated with a significant reduction in 30-day (2.9% versus 3.0%, p=0.81) and 1-year mortality (5.1% versus 5.2%, p=0.81), as compared to balloon angioplasty. However, a significant relationship was observed between patient's risk profile and mortality benefits from coronary stenting at 30-day (beta -0.63 [-25.4; -2.45], p=0.022) and 1-year follow-up (beta -0.61 [-15.9; -0.76], p=0.034). Stenting was associated with benefits in terms of TVR at both 30-day (3.1% versus 5.1%, p<0.0001) and 6 to 12 months (11.3% versus 18.4%, p<0.0001) follow-up, without any difference in terms of reinfarction.

CONCLUSIONS

Among AMI patients undergoing primary angioplasty, coronary stent implantation, when anatomically and technically feasible, may be considered, in addition to benefits in terms of TVR, to reduce mortality in high-risk patients, who may be identified by the use of validated risk scores.

A quantitative estimate of bare-metal stenting compared with balloon angioplasty in patients with acute myocardial infarction: angiographic measures in relation to clinical outcome

We performed a systematic review of all randomised controlled trials (RCTs) from the pre-drug-eluting-stent era comparing bare-metal stenting (BMS) with balloon angioplasty in patients with acute myocardial infarction (MI) to examine coronary angiographic parameters of infarct-related vessel patency and to relate the angiographic measures to clinical outcome. The search was restricted to published RCTs in humans. 10 RCTs, (6192 patients) were analysed. Compared with balloon angioplasty, BMS was associated with reduced rates of reocclusion (6.7% vs 10.1%, OR 0.62, 95% CI 0.40 to 0.96, p = 0.03) and restenosis (23.9% vs 39.3%, OR 0.45, 95% CI 0.34 to 0.59, p<0.001), but not with reduced rates of subacute thrombosis (1.7% in both groups). BMS showed a reduction in target vessel revascularisation (TVR; 12.2% vs 19.2%, OR 0.50, 95% CI 0.37 to 0.69, p<0.001), but not in mortality (5.3% vs 5.1%) or reinfarction (3.9% vs 4%). The findings of this study support BMS placement in acute MI. The discrepancy between angiographic and clinical parameters has important implications for future studies investigating further technical improvements in mechanical reperfusion therapy.

Results of primary percutaneous coronary intervention in a consecutive group of patients with acute ST elevation myocardial infarction at a tertiary Australian centre

BACKGROUND

Multicentre randomized controlled trials (RCT) of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) have consistently shown lower mortality compared with fibrinolysis, if carried out in a timely manner. Although primary PCI is now standard of care in many centres, it remains unknown whether results from RCT of selected patients are generalizable to a 'real-world' Australian setting. The primary goal of this study was to evaluate whether a strategy of routine invasive management for patients with STEMI can achieve 30-day and 12-month mortality rates comparable with multicentre RCT. Secondary goals were to determine 30-day mortality rates in prespecified high-risk subgroups, and symptom-onset- and door-to-balloon-inflation times.

METHODS

A retrospective observational study of 189 consecutive patients treated with primary PCI for STEMI in a single Australian centre performing PCI for acute STEMI.

RESULTS

All-cause mortality was 6.9% at 30 days, and 10.4% at 12 months. Mortality in patients presenting without cardiogenic shock was low (2.4% at 30 days; 5.0% at 12 months), whereas 12-month mortality in patients with shock was higher, particularly in the elderly (29.4% for patients <75 years; 85.7% for patients > or =75 years, P = 0.01). Symptom-onset-to-balloon-inflation time was < or =4 h in 56% of patients (median 231 min); however, a door-to-balloon time of <90 min was achieved in only 20% (median 133 min).

CONCLUSION

Mortality and symptom-onset-to-balloon-inflation times reported in RCT of primary PCI for STEMI are generalizable to 'real-world' Australian practice; however, further efforts to reduce door-to-balloon times are required.

Comparison between stenting and balloon in elderly patients undergoing primary angioplasty for ST-segment elevation myocardial infarction

BACKGROUND

Coronary stenting has been shown to improve clinical outcome in comparison with balloon angioplasty in patients with ST-segment elevation myocardial infarction (STEMI). However, few data have been reported so far in the elderly. Thus, the aim of the current study was to evaluate the benefits from routine stenting in this high-risk subset of patients.

METHODS

In the Zwolle-6 randomized trial a total of 1683 consecutive patients with STEMI was randomized to stenting or balloon angioplasty without any exclusion criteria. One year follow-up data were available from all patients.

RESULTS

Among a total of 143 patients older than 75 years, 73 were randomized to stent and 67 to balloon angioplasty. No difference was observed in 1-year mortality (17.1% vs 11.9%, p=NS), reinfarction (9.2% vs 11.9%, p=NS), target vessel revascularization (15.8% vs 14.9%, p=NS) or major adverse cardiac events (28.9% vs 26.9%, p=NS) between the groups at 1-year follow-up.

CONCLUSION

In conclusion, our study showed that as compared to balloon angioplasty, the clinical benefits of routine coronary stenting in the setting of acute myocardial infarction may not be necessarily applicable to elderly patients.

Time to reperfusion in acute myocardial infarction. It is time to reduce it!

BACKGROUND AND OBJECTIVES

Mortality from ST-segment elevation myocardial infarction remains high, with most deaths occurring before hospital admission. Despite effective pre- and in-hospital reperfusion strategies becoming standard over the past 2 decades, time-to-admission and time-to-treatment remain prolonged. We reviewed temporal trends in these times in published clinical trials.

METHODS

All major randomized clinical trials reporting on reperfusion strategies for acute myocardial infarction published between 1993 and 2003 were evaluated. Strategies included pre- and in-hospital thrombolysis, primary percutaneous coronary intervention (pPCI) with or without transfer, and "facilitated" PCI. We generated overall estimates of time-to-admission, time-to-treatment, door-to-balloon (DTB), and door-to-needle (DTN) times and evaluated temporal trends in the length of time-to-admission and time-to-treatment.

RESULTS

In studies that evaluated only in-hospital thrombolysis, the time-to-admission was 149 +/- 45 minutes; the mean time-to-treatment was 181 +/- 29 minutes. In studies that considered only in-hospital pPCI (without transfer), the mean time-to-admission was 153 +/- 41 minutes; the mean time-to-treatment was 234 +/- 43 minutes. In studies that compared in-hospital pPCI with in-hospital thrombolytic therapy, the mean time-to-admission was 155 +/- 47 and 150 +/- 48 minutes, respectively. The DTN time was 65 +/- 10 minutes, whereas DTB time was 81 +/- 39 minutes. In other trials evaluating in-hospital thrombolysis and pPCI with transfer to a referral center, the time-to-admission in subjects treated with thrombolysis (n = 1345) was 127 +/- 32 minutes vs 131 +/- 36 minutes for pPCI (n = 1528). For in-hospital thrombolysis, time-to-treatment was 151 +/- 23 minutes vs 203 +/- 15 minutes for pPCI patients with transfer. The DTN time in the thrombolysis group was 44 +/- 28 minutes as compared with DTB time of 78 +/- 38 minutes in the pPCI group. Throughout the last decade, time-to-admission decreased significantly (P = .02) but time-to-treatment remained unchanged (P = .38) for patients undergoing thrombolysis. In the pPCI arm, time-to-admission remained unchanged (P = .11) but a insignificant trend toward reduction was demonstrated in time-to-treatment (P = .11).

CONCLUSION

Time-to-admission and time-to-treatment for ST-segment elevation myocardial infarction are still prolonged. Resources should be directed to early recognition of the acute myocardial infarction, improved utilization of emergency services for transportation, and prehospital diagnosis and triaging. Ambulances equipped with wireless capability to transmit electrocardiograms to the on-call cardiologist seem to be promising tools to achieve earlier diagnosis and triaging with high diagnostic sensitivity and specificity.

Prospective, Multicenter Study of Thrombectomy in Patients with Acute Myocardial Infarction: The X-Tract AMI Registry

BACKGROUND

Thrombus and soft, friable atheromatous plaque are present in the majority of patients with acute myocardial infarction (AMI), and may result in distal embolization and no reflow during primary angioplasty. Thrombectomy prior to intervention may decrease thromboembolic complications and improve outcomes.

METHODS

The X-TRACT AMI registry was a prospective, multicenter study evaluating the safety and feasibility of the X-Sizer thrombectomy system prior to primary angioplasty in native coronary arteries and saphenous vein grafts (SVGs) in patients presenting within 24 hours AMI onset.

RESULTS

A total of 216 patients (220 target lesions) with AMI were enrolled at 28 U.S. sites, with approximately 90% of lesions in native coronary arteries and 10% in SVGs. Preprocedural TIMI 0/1 flow was present in 56% of patients, with thrombus in 76%. Glycoprotein IIb/IIIa inhibitors were used in 86% of patients, and bare metal stents were implanted in 94% (mean stent length 26 mm). TIMI-3 flow was present in 27% of patients at baseline, in 81% after thrombectomy, and in 92% following PCI. Normal myocardial blush grade 3 was present in 6% of patients at baseline, and in 52% postprocedure. At 30 and 360 days, 93.1% and 80.8% of patients were free from major cardiovascular events.

CONCLUSION

In this broad multicenter experience, use of the X-Sizer device prior to stent implantation in thrombus containing native coronary arteries and diseased SVGs was feasible and associated with high rates of normalized postprocedural epicardial blood flow and myocardial blush, warranting further study as an adjunct during primary angioplasty.

Comparison between stenting and balloon angioplasty in patients undergoing primary angioplasty of small coronary vessels

BACKGROUND

Primary angioplasty has been shown to improve outcomes in selected patients with ST-segment elevation myocardial infarction. However, no information has been reported so far in small vessels. In the Zwolle-6 randomized trial, consecutive patients with ST-segment elevation myocardial infarction were randomized to stenting or to balloon angioplasty without any exclusion criterion. In this study, we present data on patients with small vessels (< 3.0 mm).

METHODS

From April 1997 to October 2001, 798 patients randomized to balloon angioplasty or to stenting before their initial angiogram underwent primary angioplasty of small vessels, defined according to a postprocedural reference diameter < or = 3 mm. One-year follow-up data were available from all patients.

RESULTS

Three hundred eighty-seven patients were randomized to stent, whereas 411 were to balloon. The crossover rates from balloon to stent and from stent to balloon were 28% and 13.9%, respectively (P < .001). The groups were comparable in terms of postprocedural TIMI flow, myocardial blush grade, distal embolization, and ST-segment resolution. No difference was observed in 1-year mortality (7.2% vs 5.8%, P = not significant [NS]), target vessel revascularization (17.8% vs 22.1%, P = NS), and major adverse cardiac events (24.8% vs 29.0%, P = NS) between the groups.

CONCLUSIONS

As compared with balloon angioplasty, routine stenting does not seem to improve clinical outcomes in patients undergoing primary angioplasty of small vessels. Future trials are certainly needed to evaluate the safety and benefits of drug-eluting stents in this high-risk subset of patients.

Sirolimus-eluting versus uncoated stents in acute myocardial infarction

BACKGROUND

Sirolimus-eluting stents reduce rates of restenosis and reintervention, as compared with uncoated stents. Data are limited regarding the safety and efficacy of such stents in primary percutaneous coronary intervention (PCI) for acute myocardial infarction with ST-segment elevation.

METHODS

We performed a single-blind, multicenter, prospectively randomized trial to compare sirolimus-eluting stents with uncoated stents in primary PCI for acute myocardial infarction with ST-segment elevation. The trial included 712 patients at 48 medical centers. The primary end point was target-vessel failure at 1 year after the procedure, defined as target-vessel-related death, recurrent myocardial infarction, or target-vessel revascularization. A follow-up angiographic substudy was performed at 8 months among 174 patients from selected centers.

RESULTS

The rate of the primary end point was significantly lower in the sirolimus-stent group than in the uncoated-stent group (7.3% vs. 14.3%, P=0.004). This reduction was driven by a decrease in the rate of target-vessel revascularization (5.6% and 13.4%, respectively; P<0.001). There was no significant difference between the two groups in the rate of death (2.3% and 2.2%, respectively; P=1.00), reinfarction (1.1% and 1.4%, respectively; P=1.00), or stent thrombosis (3.4% and 3.6%, respectively; P=1.00). The degree of neointimal proliferation, as assessed by the mean (+/-SD) in-stent late luminal loss, was significantly lower in the sirolimus-stent group (0.14+/-0.49 mm, vs. 0.83+/-0.52 mm in the uncoated stent group; P<0.001).

CONCLUSIONS

Among selected patients with acute myocardial infarction, the use of sirolimus-eluting stents significantly reduced the rate of target-vessel revascularization at 1 year. (ClinicalTrials.gov number, NCT00232830 [ClinicalTrials.gov].).

Impact of routine stenting on myocardial perfusion and the extent of myocardial necrosis in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction

BACKGROUND

Primary stenting for ST-segment elevation myocardial infarction (STEMI) has been shown to improve the outcome because of the benefits in terms of restenosis. However, still controversial are the benefits in terms of reperfusion. In the Zwolle-6 randomized trial, a consecutive cohort of patients with STEMI was randomized to balloon angioplasty or stenting, without exclusion criteria. In this study, we analyzed data on myocardial perfusion and the extent of myocardial necrosis.

METHODS

From April 1997 to October 2001, a total of 1683 consecutive patients with STEMI were randomized to stenting or balloon angioplasty. No exclusion criteria were applied. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. The extent of myocardial necrosis was evaluated by enzymatic infarct size and predischarge ejection fraction. All data were prospectively collected.

RESULTS

A total of 785 patients (92.5%) in the stent group and 763 patients (91.5%) in balloon group underwent primary angioplasty. The 2 groups showed similar baseline characteristics. No difference was observed between stent and balloon in myocardial blush grade, complete ST-segment resolution, distal embolization, enzymatic infarct size, and predischarge ejection fraction at both intention-to-treat and actual treatment analysis, even when restricted to patients with anterior infarction. Time delay to treatment (earlier or later than 6 hours) did not affect the results. No difference was observed in 1-year mortality (6.0% vs 5.9%, P = NS).

CONCLUSIONS

As compared with balloon angioplasty, routine stenting does not improve myocardial perfusion, the rate of distal embolization, and the extent of myocardial necrosis in a large cohort of unselected patients with STEMI.

A new approach of primary angioplasty for ST-elevation acute myocardial infarction based on minimalist immediate mechanical intervention

OBJECTIVES

No reflow has been reported in 12-30% of the patients directly revascularized by angioplasty for acute ST elevation myocardial infarction with the highest incidence after primary stenting in patients with initial thrombolysis in myocardial infarction (TIMI) grade 0 flow. We hypothesized that a minimalist immediate mechanical intervention (MIMI) based on the use of very small size balloons to avoid both large dissection and distal embolization may be sufficient to restore flow in emergency and that recanalization may be sustained by maximized antithrombotic regimen (abcximab, clopidogrel, aspirin and heparin) allowing one to postpone stenting in better conditions.

METHODS

MIMI was performed in 93 patients for ST elevation myocardial infarction with initial TIMI grade 0 flow.

RESULTS

MIMI resulted in a TIMI grade 3 flow in 77/93 patients (83%). Immediate stenting was performed in the 16 patients with failed MIMI and resulted in a TIMI grade 3 flow in nine (56%). The residual stenosis after MIMI was 81+/-11% and ST segment resolution (> or =50%) at 1 h after reperfusion was obtained in 84%. Stenting was performed the following days in 52 patients with a post-stenting TIMI grade 3 flow in 50 (96%; 100% when stenting done beyond 24 h). No reocclusion occurred between MIMI and stenting. Among the 25 patients without stenting, six had mild stenosis at control angiogram and underwent medical treatment whereas 19 had multiple vessel disease and underwent bypass surgery.

CONCLUSIONS

MIMI combined with maximized antithrombotic therapy results in immediate and sustained recanalization with a high rate of ST resolution in a majority of patients with ST elevation myocardial infarction. This approach allows one to postpone stenting in more stable conditions with a low rate of TIMI flow deterioration or to schedule more appropriate medical or surgical alternative management.

Comparison of outcomes in acute myocardial infarction treated with coronary angioplasty alone versus coronary stent implantation

Randomized trials have demonstrated the superiority of primary angioplasty with stent implantation over balloon angioplasty alone in the treatment of acute myocardial infarction (AMI). However, it remains unknown whether the beneficial outcomes that are attained in clinical trials can be generalized to community-based practice. We conducted a retrospective cohort study of all patients who underwent primary angioplasty for AMI in New York State in 1998 and 1999. In total, 6,010 consecutive patients who presented within 23 hours of an AMI were identified for this analysis. In-hospital mortality was the primary end point. Stents were placed in 5,225 patients (87%). Patients who received stents were younger (61 vs 62 years, p = 0.011) and less often women (29% vs 33%, p = 0.018). Patients who received stents were less likely to have a history of hypertension (56% vs 61%, p = 0.013), diabetes (17% vs 24%, p <0.001), a creatinine level > or = 2.5 mg/dl (0.8% vs 2.0%, p = 0.002), 3-vessel coronary disease (14% vs 19%, p <0.001), and left main disease (2.4% vs 4.6%, p <0.001). Stent use was associated with significant decreases in length of stay (5.9 vs 8.1 day, p <0.001), major adverse cardiovascular events (4.1% vs 12%, p <0.001), and in-hospital mortality (3.5% vs 9.3%, p <0.001). After multivariate logistic regression analysis to adjust for differences in baseline characteristics, stent use was associated with a 50% decrease in risk of in-hospital mortality (odds ratio 0.474, 95% confidence interval 0.311 to 0.723, p = 0.001).

Comparison of coronary stenting versus conventional balloon angioplasty on five-year mortality in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

Little is known about the influence of stenting versus balloon angioplasty on long-term outcomes (particularly mortality) after primary percutaneous coronary intervention (PCI). We evaluated 2,087 patients with ST-elevation myocardial infarction enrolled in various Primary Angioplasty in Myocardial Infarction (PAMI) trials in the United States, who underwent primary PCI. The main outcome was all-cause mortality at 5 years, obtained through the National Death Index. Of the 2,087 patients, stenting was performed in 692 (33%). The absolute difference in the hospital (2.2% vs 3.3%), 1-year (3.3% vs 5.2%), and 5-year (10% vs 13%) mortality rates favored patients receiving a stent versus conventional balloon therapy, with the difference increasing with time. A multivariate Cox model identified stent use (vs balloon alone) as an independent correlate of lower 5-year mortality (hazard ratio 0.60, 95% confidence interval 0.42 to 0.85). The absolute reduction in mortality was greatest in the highest risk group. In conclusion, compared with balloon angioplasty, stenting during primary PCI not only resulted in better angiographic and short-term outcomes, but also in a sustained beneficial effect on mortality at 5 years. These data support the routine use of coronary stenting in most patients undergoing primary PCI, when feasible.

Direct versus conventional stent implantation in patients with acute coronary syndrome just before the era of drug-eluting stents

BACKGROUND

Direct stent implantation in patients, who undergo elective percutaneous coronary intervention (PCI) can be performed with a high success rate and clinical results that are comparable to those after predilatation. It was the aim of this prospective study to compare clinical, angiographic and procedural parameter of direct stent implantation (DS) and conventional stent implantation (CS) in patients with acute coronary syndrome (ACS).

PATIENTS AND METHODS

We analysed 194 patients with ACS (ST-elevation myocardial infarction 66%, non-ST-elevation myocardial infarction 18%, unstable angina 16%), in whom primary PCI was performed between January and December 2002. In 156 (80%) patients glycoprotein IIb/IIIa inhibitors were administered during the procedure. In 73 patients (38%) direct stent implantation could be performed successfully. In 12 patients (6%) direct stent implantation failed due to the inability to pass the stenosis. In 121 patients (62%) the stent was implanted after predilatation.

RESULTS

The clinical parameters were comparable in both groups. Reference luminal diameter before stent implantation did not differ in both groups (DS 3.01+/-0.54 vs. CS 2.84+/-0.43 mm). The final minimal luminal diameter was significantly higher in the DS group (DS 2.95+/-0.45 vs. CS 2.77+/-0.47 mm, p=0.01). The procedural time (DS 41.0+/-14.1 vs. CS 46.8+/-16.9 min, p=0.02), radiation exposure time (DS 7.3+/-4.6 vs. CS 8.9+/-4.6 min, p=0.002) and the amount of contrast agent (DS 216+/-90 vs. CS 235+/-79 ml, p=0.03) could be decreased by the technique of direct stent implantation. The incidence of major adverse cardiac events (death, myocardial infarction, CABG) during hospitalization was 4.1% in the DS group and 11.5% in the CS group (p=0.11).

CONCLUSIONS

Direct stent implantation is safe and feasible in patients with acute coronary syndromes. The procedural time, radiation exposure time and the amount of contrast agent can be significantly decreased using the technique of direct stent implantation. The incidence of major adverse cardiac events was not significantly different in this subset of patients.

A Cost-Effectiveness Analysis of a Hypothetical Catheter-Based Strategy for the Detection and Treatment of Vulnerable Coronary Plaques with Drug-Eluting Stents

AIM

Extensive efforts are underway to develop methods for the detection and treatment of vulnerable/high-risk coronary artery plaques. We utilized decision analysis to evaluate the hypothetical clinical benefits and cost-effectiveness of a catheter-based strategy.

METHODS AND RESULTS

Currently, stenotic coronary plaques are treated without regard to vulnerability. In a new strategy, vulnerable coronary plaques are detected with a catheter-based test and treated with a drug-eluting stent, regardless of degree of stenosis. A Markov-decision model was developed to compare the new strategy with current practice. Monte Carlo simulations were performed from a societal perspective, costs were converted to year 2003 U.S. dollars, and future costs and outcomes were discounted at 3%. Sensitivity analyses were performed to evaluate the effect of assumptions on variables such as the prevalence of vulnerable plaques and treatment effect. In 60-year-old male patients with coronary stenoses the new strategy would be less expensive and more effective than current practice (37,045 dollars vs 38,257 dollars and 10.23 vs 9.86 quality-adjusted life years (QALYs), respectively). The benefits of the new strategy were robust in sensitivity analyses (e.g., if the prevalence of vulnerable plaques in this patient group was 50% or more and the sensitivity and specificity of the new test were at least 0.80).

CONCLUSION

In selected patients with coronary artery stenosis, the detection of vulnerable plaques with a catheter-based test followed by their treatment with a drug-eluting stent could be a less expensive and more effective strategy than current practice. If applied to 1 million such patients in the United States undergoing catheterization, the new strategy would add 370,000 QALYs and save 1.2 billion dollars per year.

Coronary artery stents: identification and evaluation

First introduced in the 1980s, the coronary stent has been used to reduce the rate of arterial restenosis. Coronary stent implantation is currently a common procedure performed by interventional cardiologists, and the market for development and design is constantly expanding and evolving. This article was designed to assist pathologists in the accurate identification of coronary stents that are currently available, in addition to some that are no longer being implanted. The stents reviewed here were chosen based on frequency of use and/or occurrence in the literature. Some of the newer models have yet to undergo extensive clinical testing. The summaries accompanying each stent include concise physical descriptions and documented complications, intended to serve as a guide for the investigating pathologist.

Coronary stenting and abciximab in primary angioplasty for ST-segment-elevation myocardial infarction

Advances in anti-platelet therapy and improvement of stent deployment techniques have improved the safety and efficacy of stenting in the setting of ST-segment-elevation myocardial infarction (STEMI). However, in randomized trials, routine coronary stenting does not reduce mortality and re-infarction, compared to balloon angioplasty. Further, the benefits in target vessel revascularization seem to be reduced when applied to unselected patients with STEMI. Direct stenting represents an attractive strategy with potential benefits in terms of myocardial perfusion. Future large randomized trials are needed to evaluate whether this strategy has a significant impact on outcome, and to provide a cost-benefit analysis of the unrestricted use of drug-eluting stents in this high-risk subset of patients. The additional use of abciximab reduces mortality in primary angioplasty. Since the feasibility of long-distance transportation has been shown in several randomized trials, early pharmacological pre-treatment may confer further advantages by early recanalization and shorter ischaemic time, particularly in high-risk patients. Further randomized trials are needed to clarify the potential benefits from early abciximab administration and the potential role of small molecules in primary angioplasty for STEMI.

Initial thrombosuction with subsequent angioplasty in primary coronary intervention—comparison with conventional strategy

BACKGROUND

Large thrombus burden remains challenging in the setting of acute myocardial infarct. Initial thrombosuction (IT) followed by actual angioplasty may be advantageous over conventional strategy in primary percutaneous coronary intervention (PCI).

METHODS

With a case-control design, 22 consecutive patients receiving primary PCI with IT were designated as group 1. Another 22 well-matched patients undergoing primary PCI with conventional strategy in the same period were enrolled as group 2. Clinical and angiographic outcomes, procedural parameters and resource usage were compared.

RESULTS

Baseline characteristics were comparable, including the symptom onset-to-needle time (250+/-101 vs. 261+/-149 min, p = NS). Total procedure time (33+/-14 vs. 47+/-20 min, p = 0.011), fluoroscopy time (10+/-6 vs. 16+/-10 min, p = 0.014) and contrast medium consumption (140+/-40 vs. 170+/-50 ml, p = 0.024) were all significantly reduced with group 1. No-reflow occurred less frequently with group 1 (5% vs. 32%, p = 0.046) during intervention, and TIMI 3 flow was established more quickly (19+/-10 vs. 30+/-20 min, p = 0.024). Final TIMI 3 flow rates and stent rates were similar. The time to myocardial enzyme peak was shorter with group 1 (9.7+/-3.1 vs. 12.8+/-6.3 h, p = 0.048), but no difference was found in 3 months cumulative major cardiac adverse event rates.

CONCLUSIONS

Primary PCI with IT achieves earlier reperfusion and is more efficient in terms of time and resource, comparing to conventional strategy.

Is routine stenting for acute myocardial infarction superior to balloon angioplasty? A randomised comparison in a large cohort of unselected patients

OBJECTIVE

To evaluate the impact of routine stenting, compared with balloon angioplasty, in unselected patients presenting with ST segment elevation myocardial infarction (STEMI).

DESIGN

Randomised trial.

SETTING

Tertiary referral centre.

PARTICIPANTS

All patients presenting with STEMI randomly assigned to stenting or balloon angioplasty. No exclusion criteria were applied.

MAIN OUTCOME MEASURE

The primary end point was combined death or reinfarction at one year's follow up.

RESULTS

1683 consecutive patients with STEMI were randomly assigned before angiography to stenting (n = 849) or balloon angioplasty (n = 834). A total of 785 patients (92.5%) in the stent group and 763 patients (91.5%) in the balloon group actually underwent primary angioplasty. The groups were comparable in terms of postprocedural TIMI (thrombolysis in myocardial infarction) flow, myocardial blush grade, and distal embolisation. No difference was observed in clinical outcome at both intention to treat (14% v 12.5%, not significant) and actual treatment analyses (12.4% v 11.3%, not significant).

CONCLUSIONS

Compared with balloon angioplasty, routine stenting does not seem to reduce death and reinfarction in a large cohort of unselected patients with STEMI.

Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction

BACKGROUND

Balloon angioplasty following myocardial infarction (MI) reduces death, non-fatal MI and stroke compared to thrombolytic reperfusion. However up to 50% of patients experience restenosis and 3% to 5% recurrent myocardial infarction. Therefore, primary stenting may offer additional benefits compared to balloon angioplasty in patients with acute myocardial infarction.

OBJECTIVES

To examine whether primary stenting compared to primary balloon angioplasty reduces clinical outcomes in patients with acute myocardial infarction.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Pascal, Index medicus and The Cochrane Controlled Trials Register (The Cochrane Library) from 1979 to March 2002.

SELECTION CRITERIA

Randomised controlled trials of primary stenting or balloon angioplasty prior to the invasive procedure; intervention in native coronary arteries within 24 hours after onset of symptoms of myocardial infarction; report of death or reinfarction; and follow-up of at least 1 month. Trials were excluded when randomisation occurred after an invasive procedure and if they exclusively included patients with cardiogenic shock.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected and extracted data from identified trials. Outcomes included mortality, reinfarction, coronary artery bypass grafting, target vessel revascularization, need for vascular repair or blood transfusion. Peto odds ratios were calculated. To explore the stability of the overall treatment effect various sensitivity analyses were performed.

MAIN RESULTS

We included nine trials of 4433 participants. Odds ratios for mortality after stenting compared to balloon angioplasty at 30 days, 6 and 12 months were 1.16 (95% CI 0.78 to 1.73), 1.27 (95% CI 0.89 to 1.83), and 1.06 (95% CI 0.77 to 1.45). At 30 days, 6 and 12 months odds ratios for reinfarction after stenting compared to balloon angioplasty were 0.52 (95% CI 0.31 to 0.87), 0.67 (95% CI 0.45 to 1.00), and 0.67 (95% CI 0.45-0.98) and odds ratio for target vessel revascularization after stenting compared to balloon angioplasty were 0.45 (95%CI 0.34 to 0.60), 0.42 (95% CI 0.35 to 0.51), and 0.47 (95% CI 0.38 to 0.57). The odds ratio for post-interventional bleeding complications after stenting compared to balloon angioplasty was 1.34 (95% CI 0.95 to 1.88; test of heterogeneity p > 0.1).

AUTHORS' CONCLUSIONS

There is no evidence to suggest that primary stenting reduces mortality when compared to balloon angioplasty. Stenting seems to be associated with a reduced risk of reinfarction and target vessel revascularization, but potential confounding due to unbalanced post-interventional antithrombotic/anticoagulant therapies can not be ruled out on basis of this review.

Platelet glycoprotein IIb/IIIa inhibitors during percutaneous coronary interventions: a pharmacological and clinical review

One of the most significant advances of the last decade has been the development of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors. A large series of randomised, controlled clinical trials of these agents have shown a significant reduction in ischaemic events, not only in acute coronary syndrome patients, but also in patients who undergo elective percutaneous coronary interventions. Even though the use of oral antiplatelet and antithrombotic therapies in addition to percutaneous coronary interventions have had a significant impact in clinical outcomes after acute coronary syndromes, the use of GP IIb/IIIa inhibitors provide additional protection against recurrent ischaemia and has been identified as the pivotal mediator of platelet aggregation, making it a logical target for the control of platelet response to vascular injury. A series of key trials performed over the last few years with GP IIb/IIIa inhibitors in patients undergoing percutaneous coronary intervention, have shown a reduction in the risk of short-term death and non-fatal myocardial infarction. The pharmacology and molecular basis of GP IIb/IIIa receptor inhibition and the use of these agents in patients undergoing percutaneous coronary intervention (during acute coronary syndromes and in elective procedures) and their safety issues will be reviewed. A special emphasis has been made on the role of these agents in diabetic patients and their beneficial effect in reducing peri-procedural creatine kinase myocardial band fraction elevation and associated complications.

Impact of coronary artery stents on mortality and nonfatal myocardial infarction: meta-analysis of randomized trials comparing a strategy of routine stenting with that of balloon angioplasty

BACKGROUND

A strategy of routine stenting has been shown to reduce the need for target-vessel revascularization compared with a strategy of balloon angioplasty alone; however, the impact on mortality and frequency of nonfatal myocardial infarction is unclear. The aim of this study was to provide a quantitative comparison of the impact of coronary stenting on the rates of mortality and myocardial infarction with that of balloon angioplasty with provisional stenting.

METHODS

We performed a meta-analysis of randomized trials comparing routine coronary stenting to percutaneous transluminal coronary angioplasty (PTCA), including only those trials that used combination antiplatelet therapy (aspirin and a thienopyridine) as an adjuvant to stenting. Such trials included: the Belegian Netherlands Stent Study (BENESTENT) II, Optimal Coronary Balloon Angioplasty With Provisional Stenting Versus Primary Stent (OCBAS), Balloon Optimization vs Stent Study (BOSS), Evaluation of Platelet IIb/IIIa Inhibitor for Stenting (EPISTENT), Optimum Percutaneous Transluminal Coronary Angioplasty Compared With Routine Stent Strategy (OPUS-1), French Optimal Stenting Trial (FROST), Angioplasty or Stent (AS), and Doppler Endpoint Stenting International Investigation (DESTINI) trials for de novo coronary artery lesions; the Stent vs Percutaneous Angioplasty in Chronic Total Occlusion (SPACTO), Total Occlusion Study of Canada (TOSCA), Stent or Angioplasty after Recanalization of Chronic Coronary Occlusions (SARECCO), and Mayo-Japan Investigation for Chronic Total Occlusion (MAJIC) trials for coronary occlusions; the Primary Angioplasty Versus Stent Implantation in Acute Myocardial Infarction (PASTA), Gianturco-Roubin in Acute Myocardial Infarction (GRAMI), Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRESCO), Immediate Coronary Angioplasty with Elective Wiktor Stent Implantation Compared with Conventional Balloon Angioplasty in Acute Myocardial Infarction (STENTUIM-2), Stent Primary Angioplasty in MI (Stent-PAMI), Zwolle, and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trials for acute ST-segment elevation myocardial infarction; and the Intracoronary Stenting or Angioplasty for Restenosis Reduction in Small Arteries (ISAR-SMART), Park, Stenting in Small Arteries (SISA), and Bestent in Small Arteries (BESMART) trials for small vessels.

RESULTS

The 23 trials enrolled 10,347 patients, with 5130 patients randomized to receive stent and 5217 patients randomized to receive balloon angioplasty. A total of 902 (17 %) of patients crossed over from a strategy of balloon angioplasty to stent placement because of the inability to achieve a satisfactory result with a balloon. No significant difference was observed between the stent group and PTCA group in the rates of death or myocardial infarction, despite a significant reduction in the frequency of major adverse cardiac events (odds ratio, 0.59; 95% CI, 0.50-0.70; P <.001), which was driven entirely by a reduction in target vessel revascularization.

CONCLUSIONS

An initial strategy of stent placement versus balloon angioplasty with provisional stenting is associated with a similar mortality rate and frequency of nonfatal myocardial infarction after a mean follow-up period of 12.8 months. Patients who underwent stent placement had a significantly lower risk of major adverse cardiac events only when target revascularization is included as an end point.

Clinical outcomes of primary stenting versus balloon angioplasty in patients with myocardial infarction: a meta-analysis of randomized controlled trials

PURPOSE

To examine whether primary stenting as compared with primary balloon angioplasty reduces clinical outcomes in patients with myocardial infarction.

METHODS

Major medical databases from 1979 to March 2002 were searched for randomized controlled trials that compared primary stenting with balloon angioplasty in patients with myocardial infarction. Two independent reviewers selected and extracted data from identified trials. The outcomes were mortality at 30 days, 6 months, and 12 months; recurrent events; and bleeding.

RESULTS

Nine trials with a total of 4433 patients fulfilled the inclusion criteria. The odds ratios for mortality after stenting as compared with balloon angioplasty were 1.17 (95% confidence interval [CI]: 0.78 to 1.74) at 30 days, 1.07 (95% CI: 0.76 to 1.52) at 6 months, and 1.09 (95% CI: 0.80 to 1.50) at 12 months (P for heterogeneity >0.1 for each comparison). The odds ratios for reinfarction after stenting as compared with balloon angioplasty were 0.52 (95% CI: 0.31 to 0.87) at 30 days, 0.67 (95% CI: 0.45 to 1.00) at 6 months, and 0.67 (95% CI: 0.45 to 0.99) at 12 months; for target vessel revascularization, they were 0.46 (95% CI: 0.34 to 0.61) at 30 days, 0.42 (95% CI: 0.35 to 0.51) at 6 months, and 0.48 (95% CI: 0.39 to 0.59) at 12 months (P for heterogeneity >0.1 for all estimates with the exception of reinfarction at 12 months where P=0.08). The odds ratio for postinterventional bleeding complications after stenting as compared with balloon angioplasty was 1.34 (95% CI: 0.95 to 1.88; P for heterogeneity >0.1).

CONCLUSION

Compared with balloon angioplasty, primary stenting is not associated with lower mortality, but is associated with a lower risk of reinfarction and target vessel revascularization.

Optimizing the use of abciximab and intracoronary stents in patients with acute ST elevation myocardial infarction

Acute ST elevation myocardial infarction (STEMI) is a cause of significant morbidity and mortality in patients with coronary artery disease. Reperfusion therapy, either with thrombolytic agents or primary percutaneous coronary intervention (PCI), is the mainstay of therapy. Worldwide, systemic thrombolysis is the more commonly utilized reperfusion strategy, although an increasing number undergo primary PCI. PCI techniques and adjuvant therapies are evolving. Stents appear to be more useful than thrombolytic therapy or PTCA in acute AMI, especially in decreasing the need for subsequent target lesion revascularization. In patients with STEMI, administration of abciximab with stent placement decreased the primary endpoint [composite of major adverse cardiac events (death, reinfarction, urgent TVR)] by over 50% at 30 days in the Abciximab before Direct angioplasty and stenting in acute Myocardial Infarction Regarding Acute and Long-term follow-up (ADMIRAL) trial, and the benefit appeared to be maintained at 6 months. Despite these promising results, administration of abciximab with a stent did not afford greater benefit over stent alone in the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. The apparent lack of benefit with abciximab in the CADILLAC trial may be explained by the fact that this trial was not powered to detect differences in mortality and enrolled patients were selected after angiography, and were thus at lower risk. The adjuvant therapies of intracoronary stents and abciximab are becoming the standard of care, based on multiple studies. Stent placement during STEMI decreases the risk of restenosis and TVR. Treatment with abciximab may reduce the risk of acute adverse events in the short term.

A randomized trial comparing primary infarct artery stenting with or without abciximab in acute myocardial infarction

OBJECTIVES

We sought to evaluate the efficacy of abciximab as adjunctive therapy to routine infarct-related artery (IRA) stenting.

BACKGROUND

The impact of abciximab on the efficacy of myocardial reperfusion and the outcome of patients with acute myocardial infarction (AMI) undergoing IRA stenting have not yet been defined.

METHODS

In a randomized trial, we assigned 400 patients with AMI to undergo IRA stenting alone or stenting plus abciximab. The primary end point was a composite of death, reinfarction, target vessel revascularization (TVR), and stroke at one month.

RESULTS

The incidence of the primary end point was lower in the abciximab group than in the stent only group (4.5% and 10.5%, respectively; p = 0.023), and randomization to abciximab was independently related to the risk of the primary end point (odds ratio 0.41, 95% confidence interval 0.17 to 0.97; p = 0.041). Early ST-segment resolution was more frequent in the abciximab group (85% vs. 68%, p < 0.001). Infarct size, as assessed by one-month technetium-99m sestamibi scintigraphy, revealed smaller infarcts in the abciximab group. At six months, the cumulative difference in mortality between the groups increased (4.5% vs. 8%), and the incidence of the composite of six-month death and reinfarction was lower in the abciximab group than in the stent only group (5.5% and 13.5%, respectively; p = 0.006). Six-month repeat TVR and restenosis rates were similar in the two groups.

CONCLUSIONS

Abciximab plus IRA stenting should be considered the routine reperfusion strategy in patients with AMI undergoing primary percutaneous mechanical revascularization, especially in high-risk patients.

Outcomes of optimal or “stent-like”balloon angioplasty in acutemyocardial infarction: the CADILLAC trial

OBJECTIVES

We sought to compare outcomes between patients with acute myocardial infarction (AMI) undergoing percutaneous transluminal coronary angioplasty (PTCA) with an optimal or "stent-like" result versus patients who underwent routine stent placement.

BACKGROUND

Recent studies in patients with AMI undergoing stent implantation have suggested that PTCA may no longer be a relevant treatment modality for stent eligible lesions. However, whether routine stent placement is superior or necessary when an optimal PTCA or "stent-like" result is achieved is unknown.

METHODS

In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial, 2,082 patients with AMI were randomly assigned to undergo PTCA alone, PTCA + abciximab, stenting alone, or stenting + abciximab. Outcomes were compared in patients achieving an optimal acute PTCA result (residual core laboratory diameter stenosis <30% without significant dissection) versus those assigned to routine stenting.

RESULTS

Optimal PTCA was achieved in 40.7% of patients randomized to balloon angioplasty, including 38.5% and 42.7% assigned to PTCA alone and PTCA + abciximab, respectively. Ischemic target vessel revascularization (TVR) at 30 days occurred more frequently after optimal PTCA than routine stenting (5.1% vs. 2.3%, p = 0.007). The one-year composite adverse event rate (death, reinfarction, disabling stroke, or TVR) was greater after optimal PTCA than routine stenting (21.9% vs. 13.8%, p < 0.001), driven largely by increased rates of ischemic TVR (19.1% vs. 9.1%, p < 0.001); no significant differences were present in the rates of death, reinfarction, or disabling stroke between the two groups. Angiographic restenosis also was more common with optimal PTCA than routine stenting (36.2% vs. 22.2%, p = 0.003). Even a post-PTCA diameter stenosis of <20% (realized in 12% of patients) did not result in outcomes equivalent to stenting.

CONCLUSIONS

Even if an optimal result is achieved after primary PTCA in AMI, early and late outcomes can be further improved with routine stent implantation.

Comparison of outcomes for patients undergoing balloon angioplasty vs coronary stenting for acute myocardial infarction

Randomized clinical trials have demonstrated that coronary stenting is more successful than balloon angioplasty in improving short- and long-term outcomes. However, it remains unknown whether those results can be generalized to broad-based practice. This study aimed to determine whether the outcome for patients with acute myocardial infarction (AMI) undergoing coronary stent placement would be better than those undergoing balloon angioplasty. The risk-adjusted mortality and subsequent revascularization rates were compared for 2185 patients from a nationwide Japanese registry during 1997. A total of 1349 patients were treated with balloon angioplasty alone and 836 had stent placement. There were no statistically significant differences in the prevalence of demographic, clinical, and angiographic variables, except that the angioplasty group had a greater proportion of female patients and those with a left circumflex lesion. Unadjusted in-hospital mortality was comparable (7.6 vs 6.3%; p=0.28), despite higher angiographic success rate for the stent group (89.7 vs 97.7%; p<0.01). Adjusted odds ratio for in-hospital mortality was 0.75 (p=0.19). The same-admission bypass surgery rate was also similar. The 1.9-year post-discharge mortality rate was similar. The need for subsequent revascularization procedures was also similar, but restenosis was significantly lower in the stent group (34 vs 45%; p<0.01). The superiority of clinical outcome for stenting rather than balloon angioplasty could not be demonstrated in broad-based registry patients, despite technically successful results.