Correspondence

Revascularization Techniques in Acute Myocardial Infarction

N Engl J Med 2000; 343:1815December 14, 2000

Article

To the Editor:

Schömig et al. (Aug. 10 issue)1 report the results of a randomized clinical trial in which coronary stenting combined with platelet glycoprotein IIb/IIIa blockade (abciximab) was compared with fibrinolysis with a tissue plasminogen activator (alteplase) for the treatment of acute myocardial infarction. The authors show that myocardial salvage and clinical outcome (the incidence of recurrent infarction and survival) were significantly better in the group of patients who underwent stenting and received abciximab than in those who received alteplase.

Although not specifically stated, the main objective of the study was to assess the efficacy of each method of treatment for establishing and maintaining the patency of the infarct-related artery. The reduced need for late revascularization of the infarct-related artery in the stenting-and-abciximab group (10 percent, vs. 35 percent in the alteplase group) supports the superiority of this strategy for achieving a patent infarct-related artery. The obvious and early benefits of establishing patency of the infarct-related artery are that overall infarct size is limited and recurrent infarction in the area of myocardium at risk is prevented. This study clearly shows a benefit in the stenting-and-abciximab group with respect to these goals. However, the more subtle, long-term effects of a patent infarct-related artery on postinfarction left ventricular remodeling and on prevention of chronic heart failure are not addressed. Recent clinical and laboratory studies have clearly shown that a patent infarct-related artery has a beneficial effect on postinfarction left ventricular remodeling and the prevention of subsequent chronic heart failure.2,3

We would be interested to know whether all the late deaths (between 30 days and 6 months) in the fibrinolysis group were due to recurrent infarction or whether they were caused totally or in part by the development of chronic heart failure. (There were no late deaths in the stenting-and-abciximab group.) In addition, can the authors provide any data on the difference between the two groups in late ventricular function? Evidence of improved left ventricular function and less frequent chronic heart failure in the stenting-and-abciximab group would constitute further data to support the idea that all patients who have a myocardial infarction should have a patent infarct-related artery when they leave the hospital.

Robert C. Gorman, M.D.
Joseph H. Gorman, III, M.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283

3 References

1
Schomig A, Kastrati A, Dirschinger J, et al. Coronary stenting plus platelet glycoprotein IIb/IIIa blockade compared with tissue plasminogen activator in acute myocardial infarction. N Engl J Med 2000;343:385-391
Full Text | Web of Science | Medline

2
Hochman JS, Choo H. Limitation of myocardial infarct expansion by reperfusion independent of myocardial salvage. Circulation 1987;75:299-306
CrossRef | Web of Science | Medline

3
Hirayama A, Adachi T, Asada S, et al. Late reperfusion for acute myocardial infarction limits the dilatation of left ventricle without the reduction of infarct size. Circulation 1993;88:2565-2574
Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We appreciate the interest of Gorman and Gorman in our article. They underscore the reduction in infarct size as the primary benefit of establishing patency of the infarct-related artery in patients with acute myocardial infarction. They also point out that follow-up information from these patients, especially those who die after more than 30 days, may help highlight the role of reperfusion therapy on left ventricular remodeling and the prevention of chronic heart failure. In our trial, four patients who were treated with alteplase therapy and none of those who underwent primary stenting and received abciximab died between 30 days and 6 months after randomization. One died from recurrent myocardial infarction, and three from progressive, congestive heart failure. The results of scintigraphy in these four patients showed a mean final infarct size of 33.7 percent of the left ventricle. The completion of the quantitative analysis of left ventricular function for the entire study population will provide more detailed information on the effect of treatment on left ventricular remodeling.

Albert Schömig, M.D.
Adnan Kastrati, M.D.
Markus Schwaiger, M.D.
Technische Universität, 80636 Munich, Germany

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