Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Acute myocardial infarction (n=4433). Intervention: Primary stenting vs. Primary balloon angioplasty. Primary outcome: 30-day mortality (OR 1.16, 95% CI 0.78-1.73).

Alain Nordmann; Heiner C. Bucher; Peter Hengstler; Thomas Harr; Jim Young

doi:10.1002/14651858.cd005313

April 20, 2005Cochrane libraryOpen Access

Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction

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Key result

Primary stenting in acute myocardial infarction did not reduce 30-day mortality compared to balloon angioplasty, but reduced the risk of reinfarction.

Why the study?

Does primary stenting reduce mortality and reinfarction compared to primary balloon angioplasty in patients with acute myocardial infarction?

Key Points

To determine whether primary stenting reduces adverse clinical outcomes compared to primary balloon angioplasty in patients presenting with acute myocardial infarction.
Systematic review and meta-analysis of 9 randomized controlled trials involving 4,433 participants treated in native coronary arteries within 24 hours of acute myocardial infarction symptom onset.
Searched MEDLINE, EMBASE, Pascal, Index Medicus, and the Cochrane Controlled Trials Register from 1979 to March 2002 for trials reporting death or reinfarction with at least 1 month of follow-up.
Calculated Peto odds ratios for clinical endpoints including all-cause mortality, reinfarction, target vessel revascularization, and bleeding complications requiring vascular repair or transfusion.
Mortality odds ratios for stenting compared to balloon angioplasty showed no significant differences at 30 days (OR 1.16, 95% CI 0.78 to 1.73), 6 months (OR 1.27, 95% CI 0.89 to 1.83), or 12 months (OR 1.06, 95% CI 0.77 to 1.45).
Stenting significantly reduced target vessel revascularization at 30 days (OR 0.45, 95% CI 0.34 to 0.60), 6 months (OR 0.42, 95% CI 0.35 to 0.51), and 12 months (OR 0.47, 95% CI 0.38 to 0.57).
Risk of reinfarction was lower after stenting at 30 days (OR 0.52, 95% CI 0.31 to 0.87) and 12 months (OR 0.67, 95% CI 0.45 to 0.98), while post-interventional bleeding complications trended higher (OR 1.34, 95% CI 0.95 to 1.88).

Study Design

Type

Meta-Analysis (n=4,433)

Structured PICO

Does primary stenting reduce mortality and reinfarction compared to primary balloon angioplasty in patients with acute myocardial infarction?

P

Population

4,433 patients with acute myocardial infarction from 9 randomized controlled trials comparing primary stenting to balloon angioplasty, followed for up to 12 months.

I

Intervention

Primary stenting

C

Comparator

Primary balloon angioplasty

O

Outcome

Mortality and reinfarction at 30 days, 6 months, and 12 monthshard clinical

Main Result

Odds Ratio: 1.16 (95% CI 0.78–1.73)

Primary stenting in acute myocardial infarction reduces reinfarction and target vessel revascularization compared to balloon angioplasty, though it does not improve overall mortality.

Limitations

Inability to obtain individual patient level data, relying on published and unpublished summary reports.
Substantial variation in the quality of included trials, with few reporting concealed allocation or blinded outcome assessment.
Unbalanced cointerventions, as all trials used more aggressive post-interventional antithrombotic/anticoagulant therapies in patients assigned to stenting.
Limited external validity due to trials being conducted in specialized high-volume centers with highly pre-selected patients.
Women and elderly patients were underrepresented in the included trials.
Potential confounding due to unbalanced post-interventional antithrombotic/anticoagulant therapies

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Implication

Supports primary stenting over balloon angioplasty in acute MI to reduce reinfarction; strengthens evidence for stent preference despite neutral mortality.

Abstract

BACKGROUND: Balloon angioplasty following myocardial infarction (MI) reduces death, non-fatal MI and stroke compared to thrombolytic reperfusion. However up to 50% of patients experience restenosis and 3% to 5% recurrent myocardial infarction. Therefore, primary stenting may offer additional benefits compared to balloon angioplasty in patients with acute myocardial infarction. OBJECTIVES: To examine whether primary stenting compared to primary balloon angioplasty reduces clinical outcomes in patients with acute myocardial infarction. SEARCH STRATEGY: We searched MEDLINE, EMBASE, Pascal, Index medicus and The Cochrane Controlled Trials Register (The Cochrane Library) from 1979 to March 2002. SELECTION CRITERIA: Randomised controlled trials of primary stenting or balloon angioplasty prior to the invasive procedure; intervention in native coronary arteries within 24 hours after onset of symptoms of myocardial infarction; report of death or reinfarction; and follow-up of at least 1 month. Trials were excluded when randomisation occurred after an invasive procedure and if they exclusively included patients with cardiogenic shock. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected and extracted data from identified trials. Outcomes included mortality, reinfarction, coronary artery bypass grafting, target vessel revascularization, need for vascular repair or blood transfusion. Peto odds ratios were calculated. To explore the stability of the overall treatment effect various sensitivity analyses were performed. MAIN RESULTS: We included nine trials of 4433 participants. Odds ratios for mortality after stenting compared to balloon angioplasty at 30 days, 6 and 12 months were 1.16 (95% CI 0.78 to 1.73), 1.27 (95% CI 0.89 to 1.83), and 1.06 (95% CI 0.77 to 1.45). At 30 days, 6 and 12 months odds ratios for reinfarction after stenting compared to balloon angioplasty were 0.52 (95% CI 0.31 to 0.87), 0.67 (95% CI 0.45 to 1.00), and 0.67 (95% CI 0.45-0.98) and odds ratio for target vessel revascularization after stenting compared to balloon angioplasty were 0.45 (95%CI 0.34 to 0.60), 0.42 (95% CI 0.35 to 0.51), and 0.47 (95% CI 0.38 to 0.57). The odds ratio for post-interventional bleeding complications after stenting compared to balloon angioplasty was 1.34 (95% CI 0.95 to 1.88; test of heterogeneity p > 0.1). AUTHORS' CONCLUSIONS: There is no evidence to suggest that primary stenting reduces mortality when compared to balloon angioplasty. Stenting seems to be associated with a reduced risk of reinfarction and target vessel revascularization, but potential confounding due to unbalanced post-interventional antithrombotic/anticoagulant therapies can not be ruled out on basis of this review.

Discussion

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Cite This Study

Nordmann et al. (2005) conducted a meta-analysis in Acute myocardial infarction (n=4,433). Primary stenting vs. Primary balloon angioplasty was evaluated on 30-day mortality (OR 1.16, 95% CI 0.78-1.73). Primary stenting in acute myocardial infarction did not reduce 30-day mortality compared to balloon angioplasty, but reduced the risk of reinfarction.

synapsesocial.com/papers/6a8c1f33d5d4290f64f49e23 https://doi.org/10.1002/14651858.cd005313

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Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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