LETTER TO THE EDITOR
Detrimental effects of late artery opening
Marco Zimarino, MD*,
Sabina Gallina, MD and
Raffaele De Caterina, MD, PhD
* Institute of Cardiology,University of Chieti,Ospedale San Camillo de’ Lellis,Via Forlanini 50,66100 Chieti, Italy
Institute of Cardiology,G. D’Annunzio University,Chieti, Italy
emosax{at}yahoo.com
In reference to the recent study by Yousef et al. (1) in the Journal, we agree that percutaneous coronary interventions (PCI) for an occluded artery late after an acute myocardial infarction are not risk-free procedures, and even an immediate angiographic success may be harmful in the long term. The investigators attribute detrimental effects of late reperfusion—significantly greater one-year left ventricular (LV) end-systolic and end-diastolic volumes—to periprocedural microembolization of collateral vessels. However, as reported in the study limitations, the researchers did not routinely measure cardiac markers after PCI; therefore, no proof for such a causative mechanism exists.
An alternative explanation for this finding is that the adverse effect on remodelling of the invasive strategy is not related to the PCI procedure itself but to the extremely high rate of late events occurring in these patients in relation to a suboptimal treatment. Here the 50% rate of adverse event at one year is far higher than the 32% rate reported after stent implantation in occluded arteries, even using the now outdated Palmaz-Schatz stents and warfarin therapy (2). The use of NIR stents (3) and the suboptimal (two weeks) duration of clopidogrel therapy might be advocated as a cause of higher-than-expected restenosis and reocclusion rates in the study by Yousef et al. (1).
Moreover, LV volumes are certainly a better surrogate end point than exercise tolerance, but improvements in exercise duration and peak rate-pressure products in the intervention group are unexpectedly discordant from echocardiographic findings. Changes in mitral regurgitation severity may contribute to limitation of exercise capacity (4). The assessment of mitral regurgitation in this setting could be extremely helpful in clarifying whether detrimental effects on remodelling are uniformly found in the entire cohort of patients who underwent PCI or only in the subgroup of patients who experienced adverse events.
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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]
- Hoffmann R, Mintz GS, Haager PK, et al. Relation of stent design and stent surface material to subsequent in-stent intimal hyperplasia in coronary arteries determined by intravascular ultrasound. Am J Cardiol. 2002;89:1360–1364[CrossRef][Medline]
- Lapu-Bula R, Robert A, Van Craeynest D, et al. Contribution of exercise-induced mitral regurgitation to exercise stroke volume and exercise capacity in patients with left ventricular systolic dysfunction. Circulation. 2002;106:1342–1348[Abstract/Free Full Text]
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