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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Long-term impact of chronic total occlusion recanalisation in patients with ST-elevation myocardial infarction
Joëlle Elias1, Ivo M van Dongen1, Truls Råmunddal2
1Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Insights
Percutaneous coronary intervention for chronic total occlusions (CTO-PCI) in ST-elevation myocardial infarction (STEMI) patients did not reduce major adverse cardiac events. However, CTO-PCI did improve freedom from angina at one year.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Chronic total occlusions (CTOs) occur in 10% of ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).
- Long-term benefits of CTO-PCI remain uncertain due to a lack of randomized data.
- This study aimed to evaluate the mid-term and long-term clinical outcomes of CTO-PCI versus no CTO-PCI in STEMI patients with concurrent CTOs.
Purpose of the Study:
- To compare the long-term clinical outcomes of CTO-PCI versus CTO-No PCI in STEMI patients with concurrent CTO.
- To assess the impact of CTO-PCI on major adverse cardiac events (MACE), left ventricular function (LVF), and angina status.
Main Methods:
- The multicenter randomized EXPLORE trial enrolled 302 STEMI patients with successful primary PCI and a concurrent CTO.
- Patients were randomized to either CTO-PCI or CTO-No PCI.
- Primary endpoint was MACE (cardiac death, coronary artery bypass grafting, myocardial infarction); secondary endpoints included 1-year LVF and angina status.
Main Results:
- After a median follow-up of 3.9 years, MACE rates were similar between CTO-PCI and CTO-No PCI groups (13.5% vs 12.3%, P=0.93).
- Cardiac death was higher in the CTO-PCI arm (6.0% vs 1.0%, P=0.02), with no significant difference in all-cause mortality.
- One-year LVF was comparable, but freedom from angina was significantly higher in the CTO-PCI group (94% vs 87%, P=0.03).
Conclusions:
- CTO-PCI in STEMI patients with concurrent CTO did not reduce long-term MACE compared to no CTO-PCI.
- While LVF was similar, CTO-PCI was associated with improved freedom from angina at one year.
- The increased freedom from angina warrants further investigation.
Background:
During primary percutaneous coronary intervention (PCI), a concurrent chronic total occlusion (CTO) is found in 10% of patients with ST-elevation myocardial infarction (STEMI). Long-term benefits of CTO-PCI have been suggested; however, randomised data are lacking. Our aim was to determine mid-term and long-term clinical outcome of CTO-PCI versus CTO-No PCI in patients with STEMI with a concurrent CTO.
Methods:
The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) was a multicentre randomised trial that included 302 patients with STEMI after successful primary PCI with a concurrent CTO. Patients were randomised to either CTO-PCI or CTO-No PCI. The primary end point of the current study was occurrence of major adverse cardiac events (MACE): cardiac death, coronary artery bypass grafting and MI. Other end points were 1-year left ventricular function (LVF); LV-ejection fraction and LV end-diastolic volume and angina status.
Results:
The median long-term follow-up was 3.9 (2.1-5.0) years. MACE was not significantly different between both arms (13.5% vs 12.3%, HR 1.03, 95% CI 0.54 to 1.98; P=0.93). Cardiac death was more frequent in the CTO-PCI arm (6.0% vs 1.0%, P=0.02) with no difference in all-cause mortality (12.9% vs 6.2%, HR 2.07, 95% CI 0.84 to 5.14; P=0.11). One-year LVF did not differ between both arms. However, there were more patients with freedom of angina in the CTO-PCI arm at 1 year (94% vs 87%, P=0.03).
Conclusions:
In this randomised trial involving patients with STEMI with a concurrent CTO, CTO-PCI was not associated with a reduction in long-term MACE compared to CTO-No PCI. One-year LVF was comparable between both treatment arms. The finding that there were more patients with freedom of angina after CTO-PCI at 1-year follow-up needs further investigation.
Clinical Trial Registration:
EXPLORE trial number NTR1108 www.trialregister.nl.
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