Loss of Symptomatic Benefit in Occluded Infarct
Loss of Symptomatic Benefit in Occluded Infarct
Background The OAT found that routine late (3–28 days post-myocardial infarction) percutaneous coronary intervention (PCI) of an occluded infarct-related artery did not reduce death, reinfarction, or heart failure relative to medical treatment (MED). Angina rates were lower in PCI early, but the advantage over MED was lost by 3 years.
Methods Angina and revascularization status were collected at 4 months, then annually. We assessed whether non-protocol revascularization procedures in MED accounted for loss of the early symptomatic advantage of PCI.
Results Seven per 100 more PCI patients were angina-free at 4 months (P < .001) and 5 per 100 at 12 months (P = .005) with the difference narrowing to 1 per 100 at 3 years (P = .34). Non-protocol revascularization was more frequent in MED (5-year rate 22% vs 19% PCI, P = .05). Indications for revascularization included acute coronary syndromes (39% PCI vs 38% MED), stable angina/inducible ischemia (39% in each group), and physician preference (17% PCI vs 15% MED). Revascularization rates among patients with angina at any time during follow-up (35% of cohort) did not differ by treatment group (5-year rates 26% PCI vs 28% MED). Most symptomatic patients were treated without revascularization during follow-up (77%).
Conclusions In a large randomized clinical trial of stable post–myocardial infarction patients, the modest benefit on angina from PCI of an occluded infarct-related artery was lost by 3 years. Revascularization was slightly more common in MED during follow-up but was not driven by acute ischemia, and almost 1 in 5 procedures were attributed to physician preference alone.
In patients presenting with acute myocardial infarction (MI), early reperfusion, achieved either pharmacologically or mechanically, significantly reduces mortality and morbidity. Unfortunately, a significant subset of patients do not receive early reperfusion therapy because of late presentation. Management of these patients has been unclear but recently better defined by the OAT, which tested the hypothesis that a strategy of routine percutaneous coronary intervention (PCI) for total occlusion of the infarct-related artery in stable patients without rest angina or severe inducible ischemia would be beneficial in the subacute phase after acute MI. The results showed no reduction in the primary end point, a composite of death, myocardial reinfarction, or hospitalization for New York Heart Association class IV heart failure for such a strategy relative to medical therapy alone (MED) during a mean follow-up of 3 years. Percutaneous coronary intervention is, however, very effective at reducing symptoms in patients with chronic angina. It is unknown if a similar benefit exists when PCI is performed routinely post MI to the occluded culprit vessel, in the absence of ongoing symptoms or severe inducible ischemia. A major secondary end point of OAT was, thus, to assess if routine PCI of the occluded infarct-related vessel in the stable patient after MI resulted in less subsequent angina. Non-protocol revascularization, a possible reflection of the development of angina, was an additional secondary end point.
Abstract and Introduction
Abstract
Background The OAT found that routine late (3–28 days post-myocardial infarction) percutaneous coronary intervention (PCI) of an occluded infarct-related artery did not reduce death, reinfarction, or heart failure relative to medical treatment (MED). Angina rates were lower in PCI early, but the advantage over MED was lost by 3 years.
Methods Angina and revascularization status were collected at 4 months, then annually. We assessed whether non-protocol revascularization procedures in MED accounted for loss of the early symptomatic advantage of PCI.
Results Seven per 100 more PCI patients were angina-free at 4 months (P < .001) and 5 per 100 at 12 months (P = .005) with the difference narrowing to 1 per 100 at 3 years (P = .34). Non-protocol revascularization was more frequent in MED (5-year rate 22% vs 19% PCI, P = .05). Indications for revascularization included acute coronary syndromes (39% PCI vs 38% MED), stable angina/inducible ischemia (39% in each group), and physician preference (17% PCI vs 15% MED). Revascularization rates among patients with angina at any time during follow-up (35% of cohort) did not differ by treatment group (5-year rates 26% PCI vs 28% MED). Most symptomatic patients were treated without revascularization during follow-up (77%).
Conclusions In a large randomized clinical trial of stable post–myocardial infarction patients, the modest benefit on angina from PCI of an occluded infarct-related artery was lost by 3 years. Revascularization was slightly more common in MED during follow-up but was not driven by acute ischemia, and almost 1 in 5 procedures were attributed to physician preference alone.
Introduction
In patients presenting with acute myocardial infarction (MI), early reperfusion, achieved either pharmacologically or mechanically, significantly reduces mortality and morbidity. Unfortunately, a significant subset of patients do not receive early reperfusion therapy because of late presentation. Management of these patients has been unclear but recently better defined by the OAT, which tested the hypothesis that a strategy of routine percutaneous coronary intervention (PCI) for total occlusion of the infarct-related artery in stable patients without rest angina or severe inducible ischemia would be beneficial in the subacute phase after acute MI. The results showed no reduction in the primary end point, a composite of death, myocardial reinfarction, or hospitalization for New York Heart Association class IV heart failure for such a strategy relative to medical therapy alone (MED) during a mean follow-up of 3 years. Percutaneous coronary intervention is, however, very effective at reducing symptoms in patients with chronic angina. It is unknown if a similar benefit exists when PCI is performed routinely post MI to the occluded culprit vessel, in the absence of ongoing symptoms or severe inducible ischemia. A major secondary end point of OAT was, thus, to assess if routine PCI of the occluded infarct-related vessel in the stable patient after MI resulted in less subsequent angina. Non-protocol revascularization, a possible reflection of the development of angina, was an additional secondary end point.
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