Is PCI without stenting safe for low-risk STEMI patients?
Certain low-risk ST-segment elevation myocardial infarction (STEMI) patients can undergo percutaneous coronary intervention (PCI) without stenting, according to new findings published in EuroIntervention.[1]
“The recommended treatment for patients presenting with STEMI is timely PCI, including stent implantation,” wrote first author Jasmine Melissa Madsen, MB, with the department of cardiology at Copenhagen University Hospital in Denmark, and colleagues. “Coronary stenting and continuous improvement in the composition of the stents available to patients with acute myocardial infarction (MI) have resulted in a dramatic reduction of the incidence of restenosis. However, stenting per se has not decreased the incidence of cardiac death, and implantation of a coronary stent is accompanied by various risks of intravascular complications including stent thrombosis and in-stent restenosis.”
Madsen et al. explored data from the DANAMI-3 trial, a previously completed analysis of different revascularization strategies — including deferred stenting — among STEMI patients. All patients were treated at one of four PCI facilities in Denmark from March 2011 to February 2014.
The DANAMI-3 trial included 603 patients who underwent PCI with deferred stenting, and 84 of those patients were treated without stenting. During their deferral procedure, patients treated with no stenting had a median stenosis of 40%, median vessel diameter of 2.9 mm and median lesion length of 11.4 mm. The study’s authors compared that cohort with 590 patients treated with PCI and immediate stenting. Implanted stents had a median length of 18 mm and median diameter of 3.5 mm.
The median follow-up perido was 3.4 years. Overall, the study’s primary endpoint — a composite of all-cause mortality, recurrent MI and target vessel revascularization (TVR) — was seen in 14% of patients treated with no stenting and 16% of patients treated with immediate stenting. This difference was seen as nonsignificant, even after adjustments for potential confounders.
All-cause mortality was higher among the no stenting group (10.7%) than the immediate stenting group (8.6%), but recurrent MI and TVR rates were lower among the no stenting group (3.6% and 2.4%, respectively) than the immediate stenting group (8.6% and 6.4%, respectively). The authors noted that none of these relatively minor differences were seen as significant.
“Patients in whom it was necessary to stent immediately in order to restore a stable coronary blood flow are excluded from this cohort, and thus, the no stenting approach is therefore selected for lower-risk clinical settings,” the authors wrote. “Nevertheless, our findings indicate that it is safe to omit stenting in STEMI patients without a flow-limiting underlying stenosis in the culprit lesion and if it is possible to restore a stable coronary blood flow without stenting.”
Considering the “life-long risk of restenosis and stent thrombosis,” the authors added, stent implantation after PCI “may not be beneficial as a treatment option” for certain low-risk STEMI patients.
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.