Coronary Intervention for Persistent Occlusion after Myocardial Infarction
Judith S. Hochman, M.D., Gervasio A. Lamas, M.D., Christopher E. Buller, M.D., Vladimir Dzavik, M.D., Harmony R. Reynolds, M.D., Staci J. Abramsky, M.P.H., Sandra Forman, M.A., Witold Ruzyllo, M.D., Aldo P. Maggioni, M.D., Harvey White, M.D., Zygmunt Sadowski, M.D., Antonio C. Carvalho, M.D., Jamie M. Rankin, M.D., Jean P. Renkin, M.D., P. Gabriel Steg, M.D., Alice M. Mascette, M.D., George Sopko, M.D., Matthias E. Pfisterer, M.D., Jonathan Leor, M.D., Viliam Fridrich, M.D., Daniel B. Mark, M.D., M.P.H., Genell L. Knatterud, Ph.D., for the Occluded Artery Trial Investigators
Background It is unclear whether stable, high-risk patientswith persistent total occlusion of the infarct-related coronaryartery identified after the currently accepted period for myocardialsalvage has passed should undergo percutaneous coronary intervention(PCI) in addition to receiving optimal medical therapy to reducethe risk of subsequent events.
Methods We conducted a randomized study involving 2166 stablepatients who had total occlusion of the infarct-related artery3 to 28 days after myocardial infarction and who met a high-riskcriterion (an ejection fraction of <50% or proximal occlusion).Of these patients, 1082 were assigned to routine PCI and stentingwith optimal medical therapy, and 1084 were assigned to optimalmedical therapy alone. The primary end point was a compositeof death, myocardial reinfarction, or New York Heart Association(NYHA) class IV heart failure.
Results The 4-year cumulative primary event rate was 17.2% inthe PCI group and 15.6% in the medical therapy group (hazardratio for death, reinfarction, or heart failure in the PCI groupas compared with the medical therapy group, 1.16; 95% confidenceinterval [CI], 0.92 to 1.45; P=0.20). Rates of myocardial reinfarction(fatal and nonfatal) were 7.0% and 5.3% in the two groups, respectively(hazard ratio, 1.36; 95% CI, 0.92 to 2.00; P=0.13). Rates ofnonfatal reinfarction were 6.9% and 5.0%, respectively (hazardratio, 1.44; 95% CI, 0.96 to 2.16; P=0.08); only six reinfarctions(0.6%) were related to assigned PCI procedures. Rates of NYHAclass IV heart failure (4.4% vs. 4.5%) and death (9.1% vs. 9.4%)were similar. There was no interaction between treatment effectand any subgroup variable (age, sex, race or ethnic group, infarct-relatedartery, ejection fraction, diabetes, Killip class, and the timefrom myocardial infarction to randomization).
Conclusions PCI did not reduce the occurrence of death, reinfarction,or heart failure, and there was a trend toward excess reinfarctionduring 4 years of follow-up in stable patients with occlusionof the infarct-related artery 3 to 28 days after myocardialinfarction. (ClinicalTrials.gov number, NCT00004562
[ClinicalTrials.gov]
.)
Source Information
From the Cardiovascular Clinical Research Center, New York University School of Medicine, New York (J.S.H., H.R.R., S.J.A.); Mount Sinai Medical Center, Miami Beach, FL (G.A.L.); Vancouver General Hospital, Vancouver, BC, Canada (C.E.B.); University Health Network, Toronto General Hospital, Toronto (V.D.); Maryland Medical Research Institute, Baltimore (S.F., G.L.K.); National Institute of Cardiology, Warsaw, Poland (W.R., Z.S.); Italian Association of Hospital Cardiologists Research Center, Florence (A.P.M.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.W.); Hospital São Paulo, São Paulo (A.C.C.); Royal Perth Hospital, Perth, Australia (J.M.R.); Cliniques Universitaires St. Luc, Brussels (J.P.R.); Hôpital Bichat, Paris (P.G.S.); National Heart, Lung, and Blood Institute, Bethesda, MD (A.M.M., G.S.); University Hospital, Basel, Switzerland (M.E.P.); Sheba Medical Center, Tel Hashomer, Israel (J.L.); Slovak Institute of Cardiovascular Disease, Bratislava (V.F.); and Duke Clinical Research Institute, Durham, NC (D.B.M.). This article was published at www.nejm.org on November 14, 2006.
Address reprint requests to Dr. Hochman at the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology, New York University School of Medicine, 530 First Ave., HCC 1173, New York, NY 10016.
Persistent Coronary Occlusion after Myocardial Infarction
Anderson J. R., Nagajothi N., Velazquez-Cecena J.-L. E., Khosla S., Wong B., Erdogan O., De Luca L., Tomai F., Chua D., Lo A., Kuo I. F., Hochman J. S., Forman S., Reynolds H. R., the Occluded Artery Trial Investigators , Hillis L. D., Lange R. A.
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N Engl J Med 2007;
356:1681-1684, Apr 19, 2007.
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