Revista argentina de cardiología
versión On-line ISSN 1850-3748
MARIANI, Javier A; COHEN ARAZI, Hernán y TAJER, Carlos D. Effects of Late Reperfusion in Myocardial Infarction on Morbidity, Mortality and Left Ventricular Function: A Meta-analysis of Randomized Trials. Rev. argent. cardiol. [online]. 2008, vol.76, n.1, pp. 11-19. ISSN 1850-3748.
Objectives We conducted a meta-analysis to assess the effects of late reperfusion in myocardial infarction (the open-artery hypothesis) on morbidity, mortality and ejection fraction (EF). Material and Methods We included randomized controlled trials (RCTs) comparing percutaneous coronary angioplasty (PTCA) with medical treatment (MT) acute myocardial infarction patients (AMI) with persistent occlusion of the infarct-related artery > 12 hours, with > 3-month follow-up. Electronic and reference lists searches were performed. Results The inclusion criteria were met by 8 RCTs (n=2,972 patients); studies included between 30 and 2,166 patients (mean: 77). The time interval between AMI and PTCA was 25 hours to 26.3 days (mean: 8.3 days). In general, there was a trend towards a reduction in the risk of death [RR 0.73 (95% CI 0.46-1.16)] and an increase in the risk of AMI [RR 1.15 (95% CI 0.76-1.72)]. Patients who underwent PTCA showed a trend towards a reduction in hospital admissions due to HF [RR 0.56 (0.26-1.21)], and a significant reduction in the number of revascularization procedures [RR 0.82 (0.70-0.97)]. During follow-up, EF was 2.39 points greater in the PTCA group (-0.06-4.84). Nevertheless, when the results were analyzed according to the quality of the studies, the benefit on mortality was greater among those RCTs of poor quality [0.50 (0.25-0.99)], while no benefit was achieved among those RCTs of better quality [0.89 (0.53-1.51)]. There was no significant heterogeneity among trials, except on ejection fraction (p for heterogeneity = 0.03); a moderate level of general inconsistency was observed. There was evidence of publication bias. Conclusions The results of this meta-analysis indicate that performing a late angioplasty in occluded infarct-related arteries does not supply any additional benefit on morbidity and mortality. The enthusiastic results reported with the first small trials may be attributed to publication bias and to deficits related with the study design. Patients treated with PTCA showed a discreet increase in EF with no clinical benefits in this low-risk population, although it would be interesting to assess this outcome in patients with significant left ventricular dysfunction.
Palabras clave : Coronary Disease; Myocardial Infarction; Ventricular Remodeling; Surgery; Coronary Vessels.