Abstract and Introduction
Abstract
Background. Direct stenting (DS) is commonly used during percutaneous coronary intervention for acute myocardial infarction (AMI) to prevent distal embolization; however, no guideline recommendations exist regarding DS. We sought to compare DS with conventional stenting (CS) in patients presenting with AMI in a meta-analysis of randomized controlled trials.
Methods. Studies were identified from EMBASE, MEDLINE, and Cochrane databases. To be included, randomized controlled trials must have compared DS with CS in patients with AMI. Data were extracted and articles were critically appraised by two authors. A fixed effects model was used, with Peto odds ratios (ORs). The primary endpoint was death from cardiovascular causes.
Results. Five trials (n = 754) met the eligibility criteria. ST-segment resolution occurred in 68.9% (146/212) in the DS group vs 60.2% (127/211) in the CS group (OR, 1.51; 95% CI, 1.00–2.27; P=.05; I=52%). No-reflow occurred in 6.6% in the DS group compared with 6.9% in the CS group (OR, 0.78; 95% CI, 0.39–1.55; P=.48; I=0%). DS was associated with a significant reduction in the risk of in-hospital cardiovascular death (OR, 0.21; 95% CI, 0.06–0.77; P=.02; I=0%). No significant differences were observed in myocardial infarction (OR, 0.38; 95% CI, 0.09–1.51; P=.17; I=7%) or target lesion revascularization (OR, 1.20; 95% CI, 0.36–3.97; P=.76; I=0%).
Conclusion. Small trials suggest a potential benefit to DS in AMI. Further large-scale randomized trials are warranted to confirm the benefit of this approach.
Introduction
Percutaneous coronary artery intervention (PCI) has been shown to improve clinical outcomes in both ST-segment elevation myocardial infarction (STEMI) and non-STEMI. An emerging concept is that avoiding balloon predilation and instead direct stenting (DS) may prevent distal embolization and limit myocardial necrosis. In an acute myocardial infarction (AMI), particularly in STEMI, there is typically a large thrombus burden in the target vessel. DS has the potential to trap thrombus behind the stent, thus preventing no-reflow and increases in infarct size. Potential disadvantages of DS include failure to cross the lesion, stent undersizing, and stent underexpansion.
Currently, there are no guideline recommendations with regard to DS. Therefore, we sought to perform a meta-analysis of randomized trials to compare the clinical outcomes of DS with conventional stenting (CS) in patients presenting with AMI.