Abstract
BackgroundPatients with ST-elevation myocardial infarction (STEMI) not treated with primary or rescue percutaneous coronary intervention (PCI) are at risk for recurrent ischemia, especially when viability in the infarct-area is present. Therefore, an invasive strategy with PCI of the infarct-related coronary artery in patients with viability would reduce the occurrence of a composite end point of death, reinfarction, or unstable angina (UA).MethodsPatients admitted with an (sub)acute myocardial infarction, who were not treated by primary or rescue PCI, and who were stable during the first 48 hours after the acute event, were screened for the study. Eventually, we randomly assigned 216 patients with viability (demonstrated with low-dose dobutamine echocardiography) to an invasive or a conservative strategy. In the invasive strategy stenting of the infarct-related coronary artery was intended with abciximab as adjunct treatment. Seventy-five (75) patients without viability served as registry group. The primary endpoint was the composite of death from any cause, recurrent myocardial infarction (MI) and unstable angina at one year. As secondary endpoint the need for (repeat) revascularization procedures and anginal status were recorded.ResultsThe primary combined endpoint of death, recurrent MI and unstable angina was 7.5% (8/106) in the invasive group and 17.3% (19/110) in the conservative group (Hazard ratio 0.42; 95% confidence interval [CI] 0.18-0.96; p = 0.032). During follow up revascularization-procedures were performed in 6.6% (7/106) in the invasive group and 31.8% (35/110) in the conservative group (Hazard ratio 0.18; 95% CI 0.13-0.43; p < 0.0001). A low rate of recurrent ischemia was found in the non-viable group (5.4%) in comparison to the viable-conservative group (14.5%). (Hazard-ratio 0.35; 95% CI 0.17-1.00; p = 0.051).ConclusionWe demonstrated that after acute MI (treated with thrombolysis or without reperfusion therapy) patients with viability in the infarct-area benefit from a strategy of early in-hospital stenting of the infarct-related coronary artery. This treatment results in a long-term uneventful clinical course. The study confirmed the low risk of recurrent ischemia in patients without viability.Trial registrationClinicalTrials.gov: NCT00149591.
Highlights
Patients with ST-elevation myocardial infarction (STEMI) not treated with primary or rescue percutaneous coronary intervention (PCI) are at risk for recurrent ischemia, especially when viability in the infarctarea is present
We report the results of the Viability-guided Angioplasty after acute Myocardial Infarction (VIAMI) trial, which tested the hypothesis that a strategy of viability guided angioplasty with stenting after acute myocardial infarction (AMI) in patients treated with thrombolysis or who were too late for reperfusion therapy and remained stable for 48 hours, would reduce the occurrence of a composite end point of death, reinfarction, or unstable angina
At the start of this study, 50% of all AMI were still being treated with thrombolysis in the Netherlands
Summary
Patients with ST-elevation myocardial infarction (STEMI) not treated with primary or rescue percutaneous coronary intervention (PCI) are at risk for recurrent ischemia, especially when viability in the infarctarea is present. Optimal treatment for patients who have acute myocardial infarction with ST-segment elevation includes early reperfusion with primary PCI or thrombolytic therapy. More than 50% of patients have a significant residual stenosis and about 20-30% suffer from recurrent ischemic events because of plaque-instability in the infarct-related coronary artery [5]. Several studies have shown that after thrombolysis patients with residual viability in the infarct-area are at increased risk of recurrent ischemia or reinfarction [6,7,8,9,10,11,12,13]. Patients with viable tissue in the infarct area experienced significant less cardiac events after a revascularization procedure
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