LETTER TO THE EDITOR
Detrimental effects of late aterey opening: Reply
Zaheer Yousef, BSc, MRCP,
Simon Redwood, MD, MRCP, FACC,
Cliff Bucknall, MD, FRCP,
Neil Sulke, DM, MRCP, FACC and
Michael Marber, PhD, FRCP, FACC
Department of Cardiology, Kings College London, The Rayne Institute Guys and St Thomas’ Hospitals, London SE1 7EH United Kingdom
zyousef{at}dircon.co.uk
Zimarino et al. have based their conclusions on a comparison of events between the TOAT (1) and GISSOC (2) studies. This comparison is not justified as neither study was powered to examine clinical end points. Furthermore, the inclusion criteria of the trials differed. For example, only 50% of the stented patients within GISSOC had a prior myocardial infarction, whereas in TOAT this was 100%. Moreover, to increase the prevalence of adverse remodelling, the eligibility criteria of TOAT ensured that the stented vessel subtended a large volume of infarcted myocardium with a presumed high microvascular resistance and thus more disordered flow. In addition, 28% of events within TOAT comprised heart failure and stroke, end points that are unlikely to be related to reocclusion. Omitting these end points results in a one-year event rate of 24% in those randomized to intervention, compared to a nine-month event rate of 32% in the corresponding patients within GISSOC.
Undoubtedly, as stent designs improve, late complications will become less frequent; thus, use of drug-eluting stents (3) in TOAT and GISSOC could have resulted in fewer restenoses and reocclusions. The use of post-stent clopidogrel and other thienopyridines for only two weeks is validated and supported by Mishkel et al. (4) and Berger et al. (5).
Unfortunately, Doppler color flow mapping was not a protocol requirement in our study; therefore, quantitative assessment of resting mitral regurgitation is incomplete. Nevertheless, because all patients had single-vessel disease with left anterior descending artery occlusion, the posterior papillary muscle is likely to have been spared, making annular dilation the most probable mechanism of mitral incompetence. We agree that the increased exercise endurance observed in open-artery patients (despite increased left ventricular volumes) is paradoxical, and likely to be mediated through a placebo effect.
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References
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- Yousef ZR, Redwood SR, Bucknall CA, et al. Late intervention after anterior myocardial infarction: effects on left ventricular size, function, quality of life and exercise tolerance. Results of The Open Artery Trial (TOAT study). J Am Coll Cardiol. 2002;40:869–876[Abstract/Free Full Text]
- GISSOC investigatorsRubartelli P, Niccoli L, Verna E. Stent implantation versus balloon angioplasty in chronic coronary occlusions: results from the GISSOC trial. J Am Coll Cardiol. 1998;32:90–96[Abstract/Free Full Text]
- Morice MC, Serruys PW, Sousa JE, et al. A randomised comparison of a sirolimus-eluting stent with standard stent for coronary revascularisation. N Engl J Med. 2002;346:1773–1780[Abstract/Free Full Text]
- Mishkel GJ, Aguirre FV, Ligon RW, Rocha-Singh KJ, Lucore CL. Clopidogrel as adjunctive antiplatelet therapy during coronary stenting. J Am Coll Cardiol. 1999;34:1884–1890[Abstract/Free Full Text]
- Berger PB, Mahaffey KW, Meier SJ, et al. Safety and efficacy of only 2 weeks of ticlopidine therapy in patients at increased risk of coronary stent thrombosis: results from the Antiplatelet Therapy alone versus Lovenox plus Antiplatelet therapy in patients at increased risk of Stent Thrombosis (ATLAST) trial. Am Heart J. 2002;143:841–846[CrossRef][Medline]
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