FEATURE | Myocardial Infarction Impact of Revascularization Clinical Guideline Recommendations on US Clinical Practice

Reperfusion therapy has had a dramatic impact on the outcome of patients presenting with myo-cardial infarction (MI). Multiple stud-ies have shown that an open infarct-related artery (IRA) is associated with better outcome in patients with ST elevation MI (STEMI), and contem-porary reperfusion therapy is aimed at ensuring an open IRA.1 The benefits of reperfusion therapy decline with increasing delay between symptom onset and time to reperfu-sion; however, based on observational studies as well as small randomized controlled trials evaluating surrogate end points, it had been believed that late opening of the IRA would be as-sociated with a better long-term clini-cal outcome. Thus, these patients have routinely been treated with percuta-neous coronary intervention (PCI). As has been true for many other apparently logical clinical dogmas, a large, adequately powered random-ized controlled trial was not able to corroborate these beliefs. The 2006 Open Artery Trial (OAT) randomized 2,166 stable patients who had total occlusion of the IRA 3 to 28 days after MI, and who met one of two high-risk criteria (ejection fraction of <50 % or proximal occlusion), to routine PCI and stenting with optimal medical therapy, versus only optimal medical therapy.2 The OAT trial dem-onstrated no statistical difference be-tween the two arms of the study for the primary end point (a composite of death, myocardial reinfarction, or New York Heart Association [NYHA] class IV heart failure), or any of the components of the end point over a 4-year follow-up period. The clinical impact of the OAT study on clinical practice had not been previously eval-uated, and was the subject of Deyell et al’s study