Clinical Investigation
Acute Ischemic Heart Disease
Reinfarction after percutaneous coronary intervention or medical management using the universal definition in patients with total occlusion after myocardial infarction: Results from long-term follow-up of the Occluded Artery Trial (OAT) cohort

https://doi.org/10.1016/j.ahj.2012.01.016Get rights and content

Background

The OAT study randomized 2,201 patients with a totally occluded infarct-related artery on days 3 to 28 (>24 hours) after myocardial infarction (MI) to percutaneous coronary intervention (PCI) or medical treatment (MED). There was no difference in the primary end point of death, reinfarction, or heart failure at 2.9 or 6-year mean follow-up. However, in patients randomized to PCI, there was a trend toward a higher rate of reinfarction.

Methods

We analyzed the characteristics and types of reinfarction according to the universal definition. Independent predictors of reinfarction were determined using Cox proportional hazard models with follow-up up to 9 years.

Results

There were 169 reinfarctions: 9.4% PCI vs 8.0% MED, hazard ratio 1.31, 95% CI 0.97-1.77, P = .08. Spontaneous reinfarction (type 1) occurred with similar frequency in the groups: 4.9% PCI vs 6.7% MED, hazard ratio 0.78, 95% CI 0.53-1.15, P = .21. Rates of type 2 (secondary) and 3 (sudden death) MI were similar in both groups. There was an increase in type 4a reinfarctions (related to protocol or other PCI) (0.8% PCI vs 0.1% MED, P = .01) and type 4b reinfarctions (stent thrombosis) (2.7% PCI vs 0.6% MED, P < .001).

Multivariate predictors of reinfarction were history of PCI before study entry (P = .001), diabetes (P = .005), and absence of new Q waves with the index infarction (P = .01).

Conclusions

There was a trend for reinfarctions to be more frequent with PCI. Opening an occluded infarct-related artery in stable patients with late post-MI may expose them to a risk of subsequent reinfarction related to reocclusion and stent thrombosis.

Section snippets

Patient population

The design of the OAT study has been described in detail.3, 5 In summary, between February 2000 and June 2006, 2,201 patients were enrolled. Eligible patients had a totally occluded IRA on angiography on calendar days 3 to 28 (>24 hours) after MI, met an additional high-risk criterion (ejection fraction <50% or proximal occlusion), and were clinically stable. Exclusion criteria included NYHA class III or IV heart failure, shock, serum creatinine >2.5 mg/dL (221 μmol/L), significant left main or

Results

Review of all suspected reinfarctions submitted by sites resulted in an additional 29 events according to the universal definition that were not confirmed by the Mortality and Morbidity Classification Committee (MMCC) because they did not meet the OAT criteria defined in the original protocol (Figure 1; Table I). Of these 29 events, 9 were classified as spontaneous MI, 4 as secondary, 10 as sudden death, 4 as PCI related, 1 as stent related, and 1 as CABG related.

There were 169 reinfarctions

Discussion

In this trial of 2,201 stable patients with occluded IRAs treated medically or with PCI in the subacute-phase post-MI, we found a low rate of reinfarction that continued to accrue over 9 years of follow-up. The low rates of reinfarction illustrate the stable ischemic substrate of these patients when treated with the current medical therapy. There was a trend for more reinfarctions in patients randomized to PCI (P = .08). The reinfarctions in the PCI group were similar to those in the MED group

Conclusions

In the OAT trial, there was an ongoing low rate of reinfarction at 9 years of follow-up. Reinfarction tended to occur at a higher rate in patients randomized to PCI. Most reinfarctions were spontaneous (type 1), which occurred at a similar frequency in both randomized treatment groups. However, in the PCI group, there were more type 4a (both protocol PCI-related and other PCI-related reinfarctions) and type 4b (stent thrombosis) reinfarctions. The reinfarctions were clinically significant, with

Disclosures

Conflict of interest statement: Drs White, Reynolds, Carvalho, Liu, Martin, Pearte, Knatterud, Kruk, Cantor, Menon, and Hochman report having no conflict of interest. Dr Dzavik received consulting fees from Cordis (a Johnson & Johnson company) and Boston Scientific, speaking fees, and grant support from Cordis and Abbott Vascular. Dr Steg received consulting and speaking fees from Merck and honoraria from Schering-Plough. Dr Lamas received speaking fees from Medtronic and Guidant and consulting

Acknowledgements

We would like to thank the patients in the OAT trial, the investigators, and coordinators who enrolled and followed up the patients, Charlene Nell for secretarial assistance, and Sharon Fick for coordinating the review committee.

References (21)

  • J.S. Hochman et al.

    Design and methodology of the Occluded Artery Trial (OAT)

    Am Heart J

    (2005)
  • J.E. Udelson et al.

    The Occluded Artery Trial (OAT) Viability Ancillary Study (OAT-NUC): influence of infarct zone viability on left ventricular remodeling after percutaneous coronary intervention vs. optimal medical therapy alone

    Am Heart J

    (2011)
  • J.S. Hochman et al.

    Coronary intervention for persistent occlusion after myocardial infarction

    N Engl J Med

    (2006)
  • J.S. Hochman et al.

    Long-term effects of percutaneous coronary intervention of the totally occluded infarct-related artery in the subacute phase after myocardial infarction

    Circulation

    (2011)
  • K. Thygesen et al.

    Universal definition of myocardial infarction

    Circulation

    (2007)
  • J.S. Hochman et al.

    Persistent lack of benefit of late revascularization of the occluded coronary artery post-MI—the Occluded Artery Trial (OAT) long term results

    Circulation

    (2010)
  • S. Yusuf et al.

    Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation

    N Engl J Med

    (2001)
  • S.R. Steinhubl et al.

    Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial

    JAMA

    (2002)
  • D.E. Cutlip et al.

    Clinical end points in coronary stent trials: a case for standardized definitions

    Circulation

    (2007)
  • E.L. Kaplan et al.

    Nonparametric estimation from incomplete observation

    J Am Stat Assoc

    (1958)
There are more references available in the full text version of this article.

Cited by (33)

  • Risk Factors and Outcomes of Very Young Adults Who Experience Myocardial Infarction: The Partners YOUNG-MI Registry

    2020, American Journal of Medicine
    Citation Excerpt :

    Ascertainment of re-infarction was determined by review of all available records following the index admission. For an event to be classified as a re-infarction, discharge with a hospitalization diagnosis of myocardial infarction was required.18 All analyses were performed using Stata version 15.1 (StataCorp, College Station, Texas).

  • Type 2 Myocardial Infarction: JACC Review Topic of the Week

    2019, Journal of the American College of Cardiology
    Citation Excerpt :

    The critical principle is that there must be evidence of myocardial ischemia to diagnose T2MI. The heterogeneous epidemiology of T2MI is shown in Figure 4 (Online Table 3) (6–45). The frequency of T2MI is dependent on the population, comorbidities, disease definitions, adjudication processes, and the cTn assay and concentration thresholds used to detect myocardial injury (46).

  • High sensitivity troponin in the management of tachyarrhythmias

    2018, Cardiovascular Revascularization Medicine
    Citation Excerpt :

    However, according to the third universal definition, all the patients with a primary diagnosis of tachyarrhythmia who had a troponin rise (n = 206, 43.8%) in this study can also be categorized as having suffered a T2MI. This is significantly higher than previously reported, including 7.1% from a large Swedish registry [34] and other highly selected population studies where a prevalence of 2–5% is quoted [35–37]. Importantly, the troponin assay used in the Swedish registry was not highly sensitive.

  • Effects of timing, location and definition of reinfarction on mortality in patients with totally occluded infarct related arteries late after myocardial infarction

    2014, International Journal of Cardiology
    Citation Excerpt :

    An independent Morbidity and Mortality Classification Committee (MMCC) reviewed patient data on reinfarctions according to the original protocol definition of MI [1]. In conjunction with the long term follow-up phase of OAT, reinfarctions during the entire follow-up period were also reviewed centrally by a group of 5 investigators to permit classification according to the universal definition of MI [3,5,7]. This definition is an adapted, practical application of the universal definition of MI.

View all citing articles on Scopus
View full text