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SWISSI II bolsters the case for an early interventional approach ▸
Even after surviving myocardial infarction (MI), subclinical or “silent” ischaemia is common. The effect of percutaneous coronary intervention (PCI) on the long-term prognosis of these patients is not known.
The SWISSI II (Swiss Interventional Study on Silent Ischaemia Type II) trial was an unblinded controlled trial that randomised patients with a recent MI to PCI aimed at full revascularisation (n = 96), or to intensive anti-ischaemic drug treatment (n = 105). All patients had silent myocardial ischaemia verified by stress imaging, and one- or two-vessel coronary disease. The main outcome measure was survival free of major adverse cardiac events (cardiac events, non-fatal MI, and/or symptom-driven revascularisation).
The mean follow-up was 10.2 years; 27 major adverse cardiac events occurred in the PCI group and 67 in the anti-ischaemic drug treatment group (adjusted hazard ratio = 0.33; p<0.001). Patients in the PCI group also had lower rates of ischaemia (11.6% vs 28.9%; p = 0.03) despite receiving fewer drugs overall. Left ventricular ejection fraction was preserved in PCI patients (mean of 53.9% at baseline to 55.6%), but decreased significantly in patients receiving drug treatment (mean 59.7% at baseline to 48.8%).
Therefore in this trial, PCI compared with anti-ischaemic drug treatment reduced the long-term risk of major cardiac events. These findings do not necessarily contradict those of the recent COURAGE study, which, in contrast, recruited patients with stable angina. It should be noted that recruitment to the trial began over 16 years ago, and that many patients were treated by balloon angioplasty only. Furthermore statin and ACE inhibitor treatments were used far less frequently than they are today.
Off-label use of DES ▸
How effective and safe are drug-eluting stents (DES) when used “off-label”? Two papers from the Journal of the American Medical Association aimed at answering this question. Beohar and colleagues looked at 1-year results of the DES-COVER registry, involving 7752 patients treated with percutaneous …
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