Impact of stress testing before percutaneous coronary intervention or medical management on outcomes of patients with persistent total occlusion after myocardial infarction: analysis from the occluded artery trial

Background—In the Occluded Artery Trial (OAT), 2201 stable patients with an occluded infarctrelated artery (IRA) were randomized to percutaneous coronary intervention (PCI) or optimal medical treatment alone (MED). There was no difference in the primary endpoint of death, re-MI or heart failure (CHF). We examined the prognostic impact of pre-randomization stress testing. Methods—Stress testing was required by protocol except for patients with single vessel disease and akinesis/dyskinesis of the infarct zone. The presence of severe inducible ischemia was an exclusion criterion for OAT. We compared outcomes based on performance and results of stress testing. Results—598 (27%) patients (297 PCI, 301 MED) underwent stress testing. Radionuclide imaging or stress echocardiography was performed in 40%. Patients who had stress testing were younger (57 vs. 59 years), had higher ejection fractions (49% vs. 47%), and had lower rates of death (7.8% vs. 13.2%), class IV CHF (2.4% vs. 5.5%), and the primary endpoint (13.9% vs. 18.9%) than patients without stress testing (all p<0.01). Mild-moderate ischemia was observed in 40% of patients with stress testing, and was not related to outcomes. Among patients with inducible ischemia, outcomes were similar for PCI and MED (all p>0.1). Conclusions—In OAT, patients who underwent stress testing had better outcomes than patients who did not, likely related to differences in age and LV function. In patients managed with optimal medical therapy or PCI, mild-moderate inducible ischemia was not related to outcomes. The lack of benefit for PCI compared to MED alone was consistent regardless of whether stress testing was performed or inducible ischemia was present.

Keywords

Enfarte do miocárdio Estenose coronária Prova de esforço Angioplastia coronária de balão Stress testing Occluded artery trial Percutaneous coronary intervention