Swissi-ii trial

Although the curves started to diverge from the beginning, the difference became statistically significant only after 2 years. After 10 years, there was an advantage in favor of patients in the PCI group with an incidence rate of major adverse cardiac events of 3. This corresponds to an absolute event reduction of 6.

Table 3 summarizes the main secondary outcome measures of exercise-induced ischemia and resting LVEF as well as details on drug therapy and blood pressure control. Despite higher work loads achieved at each follow-up, patients in the PCI group had less prevalent and extensive ischemia on repeat exercise electrocardiograms and their resting LVEF remained preserved mean [SD] of It may be noteworthy that these findings were obtained on patients who received extensive anti-ischemic drug therapy compared with patients in the PCI group, in whom only a minority took these drugs Table 3.

This is the first, to our knowledge, long-term outcome study of an invasive therapy compared with an intensive anti-ischemic drug therapy in asymptomatic patients with silent ischemia after a recent MI.

We found a persistent benefit of PCI compared with optimized drug therapy. This benefit became apparent only after 2 years of observation, with survival curves continuously diverging up to the final follow-up after 10 years. The benefit of full revascularization by PCI compared with intensive anti-ischemic drug therapy was not restricted to hard events such as cardiac death or nonfatal MI only; benefits with respect to need for symptom-driven revascularization including repeat PCI for symptomatic restenosis , other angina, as well as objective signs of ischemia and long-term preservation of LVEF also emerged.

A number of retrospective 1 , 14 - 16 and prospective 17 studies have documented the prognostic impact of silent myocardial ischemia following MI. Several studies have documented the effect of medical drug therapy on angina or the total ischemic burden but objective cardiac events other than revascularization for aggravating angina were not significantly reduced. After 2 years of follow-up, revascularization, particularly coronary artery bypass graft surgery, reduced the rates of death or nonfatal MI to 4.

Patients in the present study were highly selected for absence of symptoms and documentation of silent ischemia. This makes them different from many of the patients previously reported on such as those in the Asymptomatic Cardiac Ischemia Pilot study who had silent ischemia along with symptomatic ischemia. Taken together, these findings indicate a need for PCI after MI only in the presence of symptomatic or silent ischemia but not without it.

There are several aspects and potential limitations of the present investigation. First, the trial was not blinded. To limit the risk of bias, we used objective outcomes, and a committee blinded to the treatment groups adjudicated the end points and based its decisions on hospital case records by other physicians not involved in this study.

Second, only a minority of patients were women. However, a first MI is less frequent in women than men who are younger than 60 years. Newer developments in medical and interventional therapy such as high-dose statins and clopidogrel as well as the use of stents may have improved outcomes.

Fourth, neither a particular drug nor a specific drug therapy was tested but rather an individualized anti-ischemic drug regimen with the aim to eliminate exercise-induced silent ST-depression as the proof of concept. Finally, despite formal power calculations, the sample size was relatively small.

Among patients with recent MI, silent myocardial ischemia verified by stress imaging, and 1- or 2-vessel coronary artery disease, PCI compared with anti-ischemic drug therapy reduced the long-term risk of major cardiac events. Erne ksl. Author Contributions: Drs Erne and Schoenenberger had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Role of the Sponsor: None of the funding organizations or sponsors played any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Dr Zwahlen was not compensated for his advice. Our website uses cookies to enhance your experience.

By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue. Figure 1. Trial Profile View Large Download. Figure 2. Table 1. Baseline Characteristics View Large Download. Table 2.

Event Outcomes View Large Download. Table 3. Secondary measures included exercise-induced ischemia and resting left ventricular ejection fraction during follow-up.

Results: During a mean SD follow-up of When studies with prospectively collected data are analyzed, it becomes apparent that the baseline characteristics of patients treated without success are clearly different from those who are successfully treated. Furthermore, when the collection of variables is prospective and they are included in the predictive statistical model[ 55 ], the benefit of successful treatment of CTO is cancelled out as these patients have baseline characteristics with a better prognosis than those treated without success.

In this large series, the clinical evolution of successfully treated patients was compared with unsuccessfully treated patients. Hospital mortality tended to be lower among the successfully treated patients than among those who were unsuccessfully treated 1. However, after adjustment for confounding variables, successful treatment was not associated with either reduced total mortality hazard ratio 0. The only benefit associated with success in the treatment of CTO was a lower rate of surgical revascularization.

Baseline characteristics of clinical and angiographic variables in studies included on Joyal meta-analisis[ 42 ]. One group of patients deserves special consideration. These are patients with acute coronary syndrome in which the culprit artery is treated initially, but who have another chronically occluded artery which is considered for recanalization in a second procedure.

This argument is based on the fact that these patients have a worse prognosis than patients with acute coronary syndrome with no CTO[ 56 ]. The EXPLORE clinical trial, which randomizes patients with CTO with no culprit artery after an acute coronary artery syndrome on revascularization treatment within 7 d of the ischemic event vs medical treatment[ 57 ] attempts to clarify this important issue, which is currently performed frequently without any scientific evidence.

Treatment of CTO has emerged in recent years as a result of a revolution in medical equipment that enables these patients to be managed with success rates well above those of a few years ago. However, there is an urgent need for randomized studies to support this therapy as it is not risk-free, and is very expensive. National Center for Biotechnology Information , U.

Journal List World J Cardiol v. World J Cardiol. Published online Jul Author information Article notes Copyright and License information Disclaimer. All rights reserved. This article has been cited by other articles in PMC. Abstract Over the last two decades, there has been increasing interest in new techniques for the percutaneous treatment of coronary chronic total occlusions CTO , which have a success rate that is much higher than that of a few years ago.

Keywords: Chronic total occlusion, Percutaneous coronary intervention. Open in a separate window. Table 2 Specific recommendations on the treatment of chronic total occlusion in the American and European Practice Guidelines. Evidence level B. Table 4 Findings on left ventricular ejection fraction and regional wall motion variations after percutaneous coronary intervention treatment of chronic total occlusion.

Table 5 Baseline characteristics of clinical and angiographic variables in studies included on Joyal meta-analisis[ 42 ]. References 1. Eur Heart J. Kahn JK. Angiographic suitability for catheter revascularization of total coronary occlusions in patients from a community hospital setting.

Am Heart J. Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol. Prevalence and management of coronary chronic total occlusions in a tertiary veterans affairs hospital. Catheter Cardiovasc Interv. Guidelines on myocardial revascularization. J Thorac Cardiovasc Surg.

Recanalization of isolated chronic total occlusions in patients with stable angina. Int J Cardiol. Individual components of the primary endpoint, noncardiac mortality, all-cause mortality, and angina not leading to revascularization. In the PCI group, complete revascularization was to be performed i.

By design, more patients in the medical therapy group at final follow-up were taking a beta-blocker