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Survival and Cardiac Remodeling Benefits in Patients Undergoing Late Percutaneous Coronary Intervention of the Infarct-Related Artery

Evidence From a Meta-Analysis of Randomized Controlled Trials

Antonio Abbate, MD^_*,_*, Giuseppe G.L. Biondi-Zoccai, MD, Darryn L. Appleton, MBChB^_*, Paul Erne, MD, Andreas W. Schoenenberger, MD, Michael J. Lipinski, MD^||, Pierfrancesco Agostoni, MD^¶, Imad Sheiban, MD and George W. Vetrovec, MD, FACC^_*

^_* Virginia Commonwealth University–VCU Pauley Heart Center, Richmond, Virginia
Division of Cardiology, University of Turin, Turin, Italy
Division of Cardiology, Kantonsspital Luzern, Luzern, Switzerland
Department of Internal Medicine, University Hospital of Berne, Berne, Switzerland
^|| Department of Internal Medicine, University of Virginia, Charlottesville, Virginia
^¶ Antwerp Cardiovascular Institute Middelheim, Antwerp, Belgium.

Manuscript received August 23, 2007; revised manuscript received November 21, 2007, accepted November 26, 2007.

^_* Reprint requests and correspondence: Dr. Antonio Abbate, VCU Pauley Heart Center, Virginia Commonwealth University Medical Center, 1200 East Broad Street, P.O. Box 980281, Richmond, Virginia 23298. (Email: aabbate{at}mcvh-vcu.edu).

Objectives: Our purpose was to perform a systematic review and meta-analysis of randomized trials comparing percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) with medical therapy in patients randomized >12 h after acute myocardial infarction (AMI).

Background: There is ongoing uncertainty about the risk–benefit ratio of late PCI in stable patients with AMI.

Methods: PubMed, CENTRAL, and other databases were searched (July 2007). Studies were included if they compared PCI with medical management and randomized patients >12 h and up to 60 days after AMI, and were excluded if patients were hemodynamically unstable. Odds ratios (ORs) were pooled for dichotomous outcomes, with all-cause mortality as the primary end point. Left cardiac remodeling parameters were also pooled with generic inverse-variance weighting.

Results: We retrieved 10 studies that enrolled 3,560 patients, with median time from AMI to randomization of 12 days (range 1 to 26 days), and follow-up of 2.8 years (42 days to 10 years). Randomization allocated 1,779 subjects to PCI and 1,781 to medical treatment. There were 112 (6.3%) and 149 (8.4%) deaths in the 2 groups, respectively, yielding significantly improved survival in the PCI group (OR 0.49 [95% confidence interval (CI) 0.26 to 0.94], p = 0.030). These benefits were associated with similarly favorable effects on cardiac remodeling, such as improved left ventricular ejection fraction in the PCI group (+4.4% change [95% CI 1.1 to 7.6], p = 0.009).

Conclusions: Percutaneous coronary intervention of the IRA performed late (12 h to 60 days) after AMI is associated with significant improvements in cardiac function and survival.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CI = confidence interval   IRA = infarct-related artery   LVEF = left ventricular ejection fraction   LVEDVI = left ventricular end-diastolic volume index   LVESVI = left ventricular end-systolic volume index   OR = odds ratio   PCI = percutaneous coronary intervention   RCT = randomized controlled trial   RD = risk difference   RR = relative risk

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