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A Randomized Trial of Deferred Stenting versus Immediate Stenting to Prevent No-or Slow Reflow in Acute ST-Elevation Myocardial Infarction (DEFER-STEMI).
J Am Coll Cardiol. 2014 Feb 21;
Authors: Carrick D, Oldroyd KG, McEntegart M, Haig C, Petrie MC, Eteiba H, Hood S, Owens C, Watkins S, Layland J, Lindsay M, Peat E, Rae A, Behan M, Sood A, Hillis WS, Mordi I, Mahrous A, Ahmed N, Wilson R, Lasalle L, Généreux P, Ford I, Berry C
Abstract
OBJECTIVES: To assess whether deferred stenting might reduce no-reflow and salvage myocardium in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).
BACKGROUND: No-reflow is associated with adverse outcomes in STEMI.
METHODS: A prospective single center randomized controlled proof-of-concept trial in reperfused STEMI patients with ≥ 1 risk factors for no-reflow. Randomization was to deferred stenting with an intention-to-stent 4-16 hours later or conventional treatment with immediate stenting. The primary outcome was the incidence of no/slow-reflow (TIMI ≤ 2). Cardiac magnetic resonance imaging (MRI) was performed 2 days and 6 months post-MI. Myocardial salvage was the final infarct size indexed to the initial area-at-risk.
RESULTS: Of 411 STEMI patients (11 March 2012 - 21 November 2012), 101 patients (mean age 60 years, 69% male) were randomized (n=52 deferred group, n=49 immediate stenting). The median (IQR) time to the second procedure in the deferred group was 9 (6, 12) hours. Fewer patients in the deferred stenting group had no/slow-reflow [14 (29%) vs. 3 (6%); p=0.006], no-reflow [7 (14%) vs. 1 (2%); p=0.052] and intra-procedural thrombotic events [16 (33%) vs. 5 (10%); p=0.010]. TIMI coronary flow grades at the end of PCI were higher in the deferred stenting group (p=0.018). Recurrent STEMI occurred in 2 patients in the deferred group before the second procedure. Myocardial salvage index at 6 months was greater in the deferred group [68 (54, 82%) vs. 56 (31, 72%); p=0.031].
CONCLUSION: In high risk STEMI patients, deferred stenting in primary PCI reduced no-reflow and increased myocardial salvage.
CLINICAL TRIAL REGISTRATION: NCT01717573.
PMID: 24583294 [PubMed - as supplied by publisher]