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No benefit from late invasive therapy for occluded arteries
A third of patients hospitalised with an acute myocardial infarction (MI) have persistent occlusion of the infarct related artery at 72 h, despite the availability of several effective reperfusion strategies. This has led to interest as to whether some of the benefits seen with early opening of the artery could be achieved with later opening, the so called “open artery hypothesis”. It is thought that late opening of occluded infarct related arteries after acute MI may improve survival (through lower risks of heart failure and sudden death from cardiac causes), ventricular function (revascularisation of hibernating myocardium and improved remodelling) and quality of life. To assess this hypothesis, the Occluded Artery Trial (OAT) compared percutaneous coronary intervention (PCI) with medical treatment alone in 2166 patients who had an occluded infarct-related artery 3–28 days after an MI, and found no evidence of clinical benefit from late arterial opening. This paper reports the quality of life and economic outcomes associated with the use of such a strategy.
A total of 951 patients (44% of those eligible) underwent quality-of-life assessment using a panel of tests including two principal outcome measures—the Duke Activity Status Index (DASI) for cardiac physical function (higher scores indicating better function) and the Medical Outcomes Study 36-item Short Form Health Inventory 5, which measures psychological wellbeing. Structured interviews were performed at baseline, 4, 12 and 24 months. Costs of treatments were assessed for 458/469 (98%) patients in the USA and 2-year cost effectiveness estimated.
At 4 months the medical treatment group, when compared with the PCI group, had a clinically marginal decrease of 3.4 points in the DASI score (p = 0.007). At 1 and 2 years the differences were smaller. No significant differences in psychological wellbeing were seen. For the 469 patients in the USA, cumulative 2-year costs were approximately US$7000 higher …