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Deferred stenting fails to reduce infarct size in STEMI
In a cardiac magnetic resonance substudy of the DANAMI-3–DEFER trial, routine deferred stenting did not reduce final infarct size or affect clinical outcomes in patients with STEMI.
The researchers included 510 patients with STEMI who were randomly assigned to PCI with deferred or immediate stent implantation. All patients had undergone cardiac MR examination before discharge after the index procedure as well as 3 months later.
The primary endpoint was final infarct size, and secondary endpoints included salvage index, the occurrence and severity of microvascular obstruction as determined by cardiac MR, left ventricular ejection fraction and LV volumes.
Deferred stenting, compared with immediate stenting, was not linked to a significant reduction in final infarct size (9% of LV vs. 10% of LV; P = .67), a significant difference in myocardial salvage index (66% vs. 67%; P = .8) or presence of microvascular obstruction (43% vs. 42%; P = .78), according to the data.
However, results from a post hoc analysis showed that deferred stenting reduced final infarct size in a subgroup of patients with a stent length of 24 mm or greater (6% of LV vs. 13% of LV; P = .006; P for interaction = .005).
In keeping with data from the main study, deferred stenting did not reduce cardiac events (HR = 0.97; 95% CI, 0.6-1.56).
“In the present DANAMI-3–DEFER CMR substudy, deferred stenting did not reduce infarct size or the occurrence of [microvascular obstruction] and did not improve myocardial salvage index in the entire group. Thus, we do not recommend routine deferred stenting in STEMI patients treated by primary PCI,” the researchers wrote. “However, whether deferred stenting is indicated in selected patients remains to be examined, and we did find a reduced infarct size among patients with stent length in the culprit territory of 24 mm or greater.”
In an accompanying editorial, Keith G. Oldroyd, MBChB, MD(Hons), from the West of Scotland Regional Heart and Lung Centre, Golden Jubilee National Hospital in the United Kingdom, noted that this finding was “intriguing.”
“One can speculate that these patients had a higher atherothrombotic burden in their culprit lesion, and therefore a higher risk of no-reflow, with more to gain from delaying stent implantation,” Oldroyd wrote. “Although there is clearly no justification for a routine policy of delayed stenting (and never was), there may still be room for a further study in high-risk patients with long lesions and/or TIMI flow grade 0 to 1 at baseline angiography.” – by Melissa Foster
Disclosure: One researcher reports presenting lectures for St. Jude Medical. A second researcher reports receiving speakers’ fees from Boston Scientific and St. Jude Medical and serving on the advisory board of AstraZeneca and Bayer A/S. Oldroyd reports no relevant financial disclosures.