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Background: In recent years significant progress has been made in invasive treatment of patients with acute myocardial infarction (AMI). Primary coronary stenting is currently a routine strategy which replaced primary balloon angioplasty with bailout stenting preferred in the past. Studies comparing these two strategies of stenting in AMI are scarce., Aim: To compare the immediate and long-term outcomes after primary angioplasty strategy and bailout stenting versus primary stent placement strategy in patients with AMI., Methods: We analysed data from a single-centre registry of consecutive patients with ST segment elevation myocardial infarction admitted between January 1998 and October 2003. In our centre in years 1998-2000 stenting was used only after failed or suboptimal balloon angioplasty. Starting from year 2001 we used routine primary stenting strategy. We compared these two angioplasty strategies applied in different time intervals with regard to in-hospital outcome and long-term mortality. Patients with cardiogenic shock at admission were excluded., Results: Out of a total of 1602 patients treated invasively for AMI (cardiogenic shock excluded) 479 underwent primary balloon angioplasty strategy with bailout stenting - group 1 (years 1998-2000) and 1123 were treated with primary stenting strategy - group 2 (years 2001-2003). In group 1 bailout stenting occurred in 34.4% of patients whereas in group 2 stents were implanted in 83% of patients. Patients in the balloon angioplasty group were younger, had shorter time from the onset of symptom to hospital arrival and more frequently underwent rescue coronary intervention after failed thrombolysis. In-hospital mortality was 2.9 vs. 2.4% in groups 1 and 2, respectively (p=NS). Twenty-four month mortality rate was 9.8% in group 1 and 10.06% in group 2 (p=NS)., Conclusions: 1. Effectiveness of coronary angioplasty is high and comparable in both groups. 2. In-hospital and long-term mortality and procedure-related complication rate are all low and comparable with both stenting strategies. 3. Independent factors increasing long-term mortality include: culprit vessel reocclusion, multivessel coronary disease, older age and hypertension. 4. Patients with complete patency of culprit vessel restored and with higher left ventricular ejection fraction presented lower 2-year mortality rate. 5. Bailout stenting did not increase 2-year mortality.

Due to recent advances in stent design, stenting without balloon predilation (direct stenting) has become more extensively used in patients with acute myocardial infarction (AMI). We performed a randomized study with broad inclusion criteria and early randomization after presentation to compare direct stenting with stenting after balloon predilation in patients with AMI. A total of 248 patients was randomized. After exclusion of patients not suitable for stenting, the final study group comprised 217 patients. Direct stenting strategy was feasible in 88% of patients with no meaningful complications. Final Thrombolysis In Myocardial Infarction grade 3 flow (96% vs 94%), final Thrombolysis In Myocardial Infarction myocardial perfusion grade 2 or 3 (68% vs 61%), and average ST-segment resolution after the procedure (49% vs 51%) were similar in the direct stenting and predilation groups, respectively (p = NS). Rate of in-stent restenosis was higher in the direct stenting group (30% vs 16%, p = 0.024), which was due to a worse angiographic result after the procedure. At 5 years, a composite of cardiac death, reinfarction, and target lesion revascularization had occurred in 39% in the direct stenting group and 34% in the predilated group (p = 0.40). In conclusion, although at 5 years clinical outcome did not differ significantly between groups, direct stenting was associated with a higher incidence of in-stent restenosis at 1 year. Direct stenting did not improve epicardial and myocardial reperfusion indexes. Direct stenting strategy should not be recommended in all patients with AMI as an alternative strategy to stenting after predilation.

Background: Results of studies comparing direct stenting (DS) with conventional stenting (CS) after balloon predilatation in patients with acute myocardial infarction (MI) have been reported in the past, however they are conflicting. There are only few randomised studies that aim to answer whether DS improves epicardial and myocardial patency., Aim: To assess the effects of DS on epicardial and myocardial patency in patients with acute MI., Methods: Consecutive patients with acute MI were randomised either to DS or CS strategy. Clinical exclusion criteria were as follows: clinical and electrocardiographic features of reperfusion, pulmonary oedema, cardiogenic shock, contradictions to coronarography, allergy to aspirin, ticlopidine, clopidogrel, heparin and stainless steel. Angiographic exclusion criteria were as follows: lesion <50% with correct patency in the infarct-related artery (IRA), lesion in the left main coronary artery, previously performed percutaneous coronary intervention in the target vessel, diameter of the IRA <2 mm or >4 mm. We assessed epicardial patency according to the TIMI (thrombolysis in myocardial infarction) scale and myocardial patency according to the TMPG (TIMI myocardial perfusion grade) scale. In addition, we analysed ST segment resolution in 12-lead electrocardiography (ECG). The ECG was performed before and 30 minutes after PCI., Results: We analysed 300 consecutive patients with acute ST segment elevation MI. After exclusion of patients not suitable for the study design, the DS group comprised 110 patients and the CS group - 107 patients. Clinical and angiographic results were similar in both groups. Initial TIMI 0 (48.2% vs. 43.0%), initial TIMI 3 (31.8% vs. 28.0%), initial TMPG 0-1 (77.3% vs. 78.5%), final TIMI 3 (95.5% vs. 93.5%) and final TMPG 2-3 (68.2% vs. 60.8%) were similar in the DS and CS groups, respectively (p=NS). The incidence of no-reflow phenomenon was comparable in both groups (4.5% vs. 6.5%, NS). The inclusive rate of no-reflow phenomenon plus worsening patency in the IRA were 6.4% vs. 10.3% in the DS and CS groups respectively. The ST segment resolution > or = 50% was 58.1% in the DS group and 56.1% in the CS group (NS)., Conclusions: Direct stenting does not significantly improve epicardial and myocardial patency in an unselected group of patients with acute ST segment elevation MI.