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CLINICAL STUDY

A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction

^* Institut Cardiovasculaire Paris Sud, Hôpital Claude Galien, Quincy-sous-Sénart, France

Manuscript received April 18, 2001; revised manuscript received September 18, 2001, accepted September 20, 2001.

^* Reprint requests and correspondence: Dr. Christophe Loubeyre, Institut Cardiovasculaire Paris Sud, Hôpital Privé Claude Galien, 20, Route de Boussy, 91480 Quincy-sous-Sénart, France.
c.loubeyre{at}icps.com.fr

OBJECTIVES: We sought to determine whether direct stenting might prevent the adverse events associated with stent implantation during primary angioplasty and to compare it with conventional stent implantation in patients with acute myocardial infarction (AMI).

BACKGROUND: No trial has demonstrated that stents favorably influence mortality rate. Recent studies have even suggested a negative impact of stents on coronary blood flow and clinical outcome.

METHODS: Of 409 patients treated by primary angioplasty with stent implantation in our center, 206 (50%) were enrolled in this randomized, single-center trial and allocated to direct stent implantation (n = 102) or stent implantation after balloon pre-dilation (n = 104). The study end points included angiographic results (final corrected Thrombolysis In Myocardial Infarction [TIMI] frame count and a composite end point of slow and no-reflow or distal embolization), an electrocardiogram marker of myocardial reperfusion assessment (ST-segment resolution) and in-hospital clinical outcome (death and recurrent infarction).

RESULTS: Direct stent implantation failed in eight patients but succeeded after pre-dilation in all. A non-significant increase in TIMI flow grade 3 was achieved after direct stenting (95.1% vs. 93.3%, p = 0.74) without significant difference in the corrected TIMI frame count (31.5 ± 17 and 35.2 ± 20 frames after direct and conventional stent, respectively, p = 0.42). The composite angiographic end point was significantly reduced by direct stent implantation (11.7% vs. 26.9%, p = 0.01). ST-segment resolution was also significantly improved after direct stent (no ST-segment resolution in 20.2% vs. 38.1% after direct and conventional stent, respectively, p = 0.01). Death and/or recurrent infarction occurred in six patients after conventional stent implantation and in two patients after direct stenting (p = 0.28).

CONCLUSIONS: In selected patients with AMI, direct stenting can be applied safely and effectively. This strategy may result in a significant reduction of microvascular injury, as suggested by improved ST-segment resolution after reperfusion with major potential clinical consequences.

Abbreviations and Acronyms   ADMIRAL   Abciximab Before Direct Angioplasty and Stenting in Myocardial Infarction Regarding Acute and Long-term Follow-up   AMI   acute myocardial infarction   CADILLAC   Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complication trial   cTFC   corrected Thrombolysis in Myocardial Infarction frame count   GP   glycoprotein   MI   myocardial infarction   PAMI   Primary Angioplasty in Myocardial Infarction trial   PTCA   percutaneous transluminal coronary angioplasty   STENTIM   Stenting in Acute Myocardial Infarction study   TIMI   Thrombolysis In Myocardial Infarction

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