Coronary artery disease
Comparison of Direct Stenting With Conventional Stent Implantation in Acute Myocardial Infarction

https://doi.org/10.1016/j.amjcard.2011.07.040Get rights and content

Small studies have suggested that direct stenting without balloon predilatation in ST-segment elevation myocardial infarction may reduce microcirculatory dysfunction. To examine the clinical benefits of direct stenting in a large cohort of patients who underwent primary percutaneous coronary intervention treated with contemporary pharmacotherapy, the 1-year outcomes from the multicenter, randomized Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial were analyzed. A total of 3,602 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were enrolled. The present study cohort consisted of 2,528 patients in whom single lesions (excluding bypass grafts) were treated with stent implantation. At operator discretion, direct stenting was attempted in 698 patients (27.6%), and stenting was performed after predilatation in 1,830 patients (72.4%). Propensity-score matching was performed to reduce bias. Direct stenting was successful in 677 patients (97.0%). ST-segment resolution at 60 minutes after the procedure was improved in patients who underwent direct compared to conventional stenting (median 74.8% vs 68.9%, respectively, p = 0.01). At 1-year follow-up, direct compared to conventional stenting was associated with a significantly lower rate of all-cause death (1.6% vs 3.8%, p = 0.01) and stroke (0.3% vs 1.1%, p = 0.049), with nonsignificant differences in target lesion revascularization, myocardial infarction, stent thrombosis, and major bleeding. Death at 1 year remained significantly lower in the direct stenting group after multivariate adjustment (hazard ratio 0.42, 95% confidence interval 0.21 to 0.86, p = 0.02) and in a propensity score–based analysis (hazard ratio 0.92, 95% confidence interval 0.88 to 0.95, p = 0.02). In conclusion, compared to stent implantation after predilatation, direct stenting is safe and effective in appropriately selected lesions in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention and may result in improved survival.

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Methods

HORIZONS-AMI was a prospective, open-label, multicenter, controlled trial in patients with STEMI who underwent a primary PCI management strategy, incorporating 2 factorial randomized phases to allow comparison of the direct thrombin inhibitor bivalirudin alone to heparin plus a glycoprotein IIb/IIIa inhibitor and of paclitaxel-eluting stents to BMS.10, 11

The clinical eligibility criteria for the HORIZONS-AMI trial have been previously described.10, 11 In brief, consecutive patients aged ≥18

Results

From March 25, 2005, to May 7, 2007, 3,602 patients at 123 centers in 11 countries with STEMI who underwent primary PCI were randomized to heparin plus glycoprotein IIb/IIIa inhibitors (n = 1,802) or bivalirudin alone (n = 1,800). PCI was subsequently performed in 3,345 patients (92.9%), including 3,226 patients (96.4%) in whom stenting was attempted. Direct stenting of a single de novo native coronary lesion was attempted in 698 patients (27.6%) and conventional stenting in 1,830 patients

Discussion

The present analysis from the large-scale, international HORIZONS-AMI trial suggests that direct stenting in eligible lesions in patients with STEMI may result in improved TIMI flow, ST-segment resolution, and survival, thereby confirming and extending the results of previous smaller studies.

Previous studies in modest numbers of patients have suggested that direct stenting in STEMI is feasible and may result in less distal embolization with reduced microcirculatory dysfunction and no-reflow.

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The names of the investigators, institutions, and research organizations participating in the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial have been previously published.5

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