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Late PCI After Myocardial Infarction in Stable Patients — Where’s the Benefit?

A large randomized trial suggests that medical therapy may be as beneficial as PCI in these patients.

Early revascularization during an acute ST-segment elevation myocardial infarction enhances myocardial salvage and improves short-term outcomes. However, data also suggest that an open infarct-related artery improves longer term survival, perhaps by reducing risk for arrhythmia and sudden death. This "open-artery hypothesis" has led to the practice of opening occluded infarct-related arteries, even days or weeks after the MI, when myocardial salvage is unlikely.

In a large international trial of late revascularization, investigators randomized 2166 stable patients — all of whom had total occlusion of the infarct-related artery 3 to 28 days after MI, and an ejection fraction of <50% or a proximal occlusion of a major vessel supplying a large territory — to percutaneous coronary intervention (PCI) and stenting or to no PCI; all patients received optimal medical therapy. Patients with severe heart failure or shock, serum creatinine levels >2.5 mg/dL, left-main or three-vessel coronary disease, angina at rest, or severe ischemia on stress testing were excluded. At 4 years, the incidence of the primary endpoint (death, MI, or severe heart failure) was slightly, but not significantly, higher in the PCI group than in the medical-therapy group (17.2% vs. 15.6%). The same was true for rates of MI (7.0% vs. 5.3%).

Comment: These data from a well-conducted trial challenge the open-artery hypothesis and suggest that medical therapy is as beneficial as PCI in these stable patients. Editorialists opine that PCI may still have a role in the minority of patients who cannot tolerate ß-blockers, but, in general, the data do not support routine PCI late after MI in stable patients.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine December 13, 2006

Citation(s):

Hochman JS et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006 Dec 7; 355:2395-407.

• Original article (Subscription may be required)
• Medline abstract (Free)

Hillis LD and Lange RA. Myocardial infarction and the open-artery hypothesis. N Engl J Med 2006 Dec 7; 355:2475-7.

• Original article (Subscription may be required)
• Medline abstract (Free)