Published online before print November 14, 2006, doi: 10.1161/CIRCULATIONAHA.106.669432
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(Circulation. 2006;114:2449-2457.)
© 2006 American Heart Association, Inc.
Coronary Heart Disease |
Randomized Trial of Percutaneous Coronary Intervention for Subacute Infarct-Related Coronary Artery Occlusion to Achieve Long-Term Patency and Improve Ventricular Function
The Total Occlusion Study of Canada (TOSCA)–2 Trial
avík, MD
iar, MDFrom the University Health Network, (V.D., J.R.R., D.A.), St. Michael’s Hospital (W.J.C.), Sunnybrook Health Sciences Centre (E.A.C.), University of Toronto, Toronto, Canada; Vancouver General Hospital (C.E.B., G.B.J.M.), St. Paul’s Hospital (R.J.C.), University of British Columbia, Vancouver, British Columbia, Canada; Mount Sinai Medical Center (G.A.L.), Miami Beach, Fla; Royal Perth Hospital (J.M.R.), Perth, Australia; Maryland Medical Research Institute (S.F., G.L.K.), Baltimore, Md; Hospital Fernando Fonseca (B.T.), Amadora, Portugal; Upper Silesian Medical Centre (P.B.), Katowice, Poland; Hemodynamia Rosario (C.V.), Rosario, Argentina; Hotel Dieu Hospital (A.G.), Windsor, Ontario, Canada; Central Slovak Institute for Cardiovascular Diseases (P.M.), Banská Bystrica, Slovakia; Waikato Hospital (G.D.), Hamilton, New Zealand; National Institutes of Health (A.M., G.S.), Bethesda, Md; and New York University (J.S.H.), New York, NY.
Correspondence to Vladimír Davík, MD, Division of Cardiology, University Health Network, 6-246 EN, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4. E-mail vlad.dzavik{at}uhn.on.ca
Received October 18, 2006; revision received November 6, 2006; accepted November 7, 2006.
Background— In the present study, we sought to determine whether opening a persistently occluded infarct-related artery (IRA) by percutaneous coronary intervention (PCI) in patients beyond the acute phase of myocardial infarction (MI) improves patency and indices of left ventricular (LV) size and function.
Methods and Results— Between May 2000 and July 2005, 381 patients with an occluded native IRA 3 to 28 days after MI (median 10 days) were randomized to PCI with stenting (PCI) or optimal medical therapy alone. Repeat coronary and LV angiography was performed 1 year after randomization (n=332, 87%). Coprimary end points were IRA patency and change in LV ejection fraction. Secondary end points included change in LV end-systolic and end-diastolic volume indices and wall motion. PCI was successful in 92%. At 1 year, 83% of PCI versus 25% of medical therapy–only patients had a patent IRA (P<0.001). LV ejection fraction increased significantly (P<0.001) in both groups, with no between-group difference: PCI 4.2±8.9 (n=150) versus medical therapy 3.5±8.2 (n=136; P=0.47). Median change (interquartile range) in LV end-systolic volume index was –0.5 (–9.3 to 5.0) versus 1.0 (–5.7 to 7.3) mL/m2 (P=0.10), whereas median change (interquartile range) in LV end-diastolic volume index was 3.2 (–8.2 to 13.3) versus 5.3 (–4.6 to 23.2) mL/m2 (P=0.07) in the PCI (n=86) and medical therapy–only (n=76) groups, respectively.
Conclusions— PCI with stenting of a persistently occluded IRA in the subacute phase after MI effectively maintains long-term patency but has no effect on LV ejection fraction. On the basis of these findings and the lack of clinical benefit in the main Occluded Artery Trial, routine PCI is not recommended for stable patients with a persistently occluded IRA after MI.
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