Coronary intervention for persistent occlusion after myocardial infarction

Area of Science:

• Cardiology
• Interventional Cardiology
• Clinical Trials

Background:

• Persistent total occlusion of the infarct-related coronary artery after myocardial infarction (MI) in stable, high-risk patients presents a therapeutic dilemma.
• The optimal management strategy, particularly the role of percutaneous coronary intervention (PCI) beyond the acute phase, remains unclear for preventing subsequent adverse events.

Purpose of the Study:

• To determine if routine percutaneous coronary intervention (PCI) and stenting, in addition to optimal medical therapy, reduces the risk of subsequent major adverse cardiovascular events compared to optimal medical therapy alone in stable high-risk patients with persistent total coronary artery occlusion post-MI.

Main Methods:

• A randomized controlled trial involving 2166 stable patients with total occlusion of the infarct-related artery 3 to 28 days after MI and high-risk criteria (ejection fraction <50% or proximal occlusion).
• Patients were assigned to either routine PCI with optimal medical therapy (n=1082) or optimal medical therapy alone (n=1084).
• The primary endpoint was a composite of death, myocardial reinfarction, or New York Heart Association (NYHA) class IV heart failure over 4 years.

Main Results:

• The 4-year cumulative incidence of the primary composite endpoint was similar between groups (17.2% in PCI group vs. 15.6% in medical therapy group; hazard ratio [HR], 1.16; P=0.20).
• Rates of myocardial reinfarction were numerically higher in the PCI group (7.0% vs. 5.3%; HR, 1.36; P=0.13), with a trend toward excess nonfatal reinfarctions (6.9% vs. 5.0%; HR, 1.44; P=0.08).
• Rates of death and NYHA class IV heart failure were comparable between the PCI and medical therapy groups.

Conclusions:

• Routine percutaneous coronary intervention (PCI) did not reduce the occurrence of death, reinfarction, or heart failure in stable patients with persistent total occlusion of the infarct-related artery.
• A trend toward excess reinfarction was observed in the PCI group during the 4-year follow-up period.
• Optimal medical therapy alone appears to be a suitable strategy for managing these patients.