Viability-Guided Angioplasty After Acute Myocardial Infarction - VIAMI

Description:

The goal of the trial was to evaluate an invasive strategy of percutaneous coronary intervention (PCI) compared with a conservative strategy among patients with recent acute myocardial infarction (MI) with viability in the infarct area.

Study Design

Patients Enrolled: 216
Mean Follow Up: 6 months
Mean Patient Age: Mean age 60 years
Female: 22

Patient Populations:

Acute or recent MI, not treated by direct or rescue angioplasty, stable during the first 48 hours after the acute event, and age <80 years

Exclusions:

Viability testing technically not possible, contraindications for dobutamine echocardiography or coronary angiography, serious life-threatening noncardiac illness, ECG abnormalities making the evaluation of the ST segment impossible (left bundle branch block, pacemaker), and an unreliable follow-up

Primary Endpoints:

Composite of death, reinfarction, and unstable angina

Secondary Endpoints:

Need for revascularization, the occurrence of angina pectoris by Canadian Cardiovascular Society classification, and the incidence of heart failure by New York Heart Association classification

Drug/Procedures Used:

Patients were evaluated by low-dose dobutamine echocardiography within 3 days of admission for the index MI. If there was unequivocal signs of viability in the infarct area, patients were randomized to an invasive strategy (n = 106) or conservative (n = 110) strategy.

In the invasive strategy, angiography was performed with intent to perform PCI with stenting of the infarct artery and abciximab. In the conservative strategy, patients underwent stress testing before hospital discharge, and if needed, angiography. Patients without viability were entered into a registry (n = 75).

Principal Findings:

At baseline, 50% of patients had been treated with thrombolysis and 32% of patients had had an anterior MI. In the invasive group, 73% of patients underwent PCI, 11% coronary artery bypass grafting, and 16% had no revascularization performed. The mean time from randomization to angiography was 2 days in the invasive group.

The primary endpoint of death, recurrent MI, or unstable angina was lower in the invasive group (6.6% vs. 15.5%, p = 0.04), driven by a reduction in unstable angina (2.8% vs. 11.8%, p = 0.012) with no difference in death (1.9% vs. 0.9%, p = NS) or recurrent MI (1.9% vs. 2.7%, p = NS). In the conservative group, elective revascularizations were performed in 17.3% of patients and any revascularization in 27.3%.

Among those with nonviable myocardium who were entered into the registry, the rate of unstable angina or recurrent MI was lower compared with those with viable myocardium treated conservatively (5.3% vs. 14.5%, p < 0.05).

Interpretation:

Among patients with recent acute MI with viability in the infarct area, as evaluated by low-dose dobutamine echocardiography within 3 days, use of an invasive strategy with angiography and revascularization was associated with a reduction in the primary endpoint of death, MI, or unstable angina at 6 months compared with a conservative strategy.

The reduction in the primary endpoint with the invasive strategy was driven by a reduction in unstable angina, with no difference in death or reinfarction. Patients without viability enrolled in the registry had a low rate overall of ischemic events at 6 months compared to those with viability.

References:

van Loon RB, Veen G, Kamp O, Bronzwaer JG, Visser CA, Visser FC. Early and long-term outcome of elective stenting of the infarct-related artery in patients with viability in the infarct-area: Rationale and design of the Viability-guided Angioplasty after acute Myocardial Infarction-trial (The VIAMI-trial). Curr Control Trials Cardiovasc Med. 2004 Nov 11;5(1):11.

Presented by G. Veen, European Society of Cardiology Scientific Congress, September 2006.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, EP Basic Science, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Myocardial Infarction, Follow-Up Studies, Platelet Aggregation Inhibitors, Immunoglobulin Fab Fragments, Electrocardiography, Percutaneous Coronary Intervention, Stents, Registries, Dobutamine, Coronary Angiography, Bundle-Branch Block, Coronary Artery Bypass, Echocardiography


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