title: A randomized comparison of direct stenting with conventional stent implantation in selected patients with acute myocardial infarction.
abstract: OBJECTIVE
  We sought to determine whether direct stenting might prevent the adverse events associated with stent implantation during primary angioplasty and to compare it with conventional stent implantation in patients with acute myocardial infarction (AMI).
  
  
  BACKGROUND
  No trial has demonstrated that stents favorably influence mortality rate. Recent studies have even suggested a negative impact of stents on coronary blood flow and clinical outcome.
  
  
  METHODS
  Of 409 patients treated by primary angioplasty with stent implantation in our center, 206 (50%) were enrolled in this randomized, single-center trial and allocated to direct stent implantation (n = 102) or stent implantation after balloon pre-dilation (n = 104). The study end points included angiographic results (final corrected Thrombolysis In Myocardial Infarction [TIMI] frame count and a composite end point of slow and no-reflow or distal embolization), an electrocardiogram marker of myocardial reperfusion assessment (ST-segment resolution) and in-hospital clinical outcome (death and recurrent infarction).
  
  
  RESULTS
  Direct stent implantation failed in eight patients but succeeded after pre-dilation in all. A non-significant increase in TIMI flow grade 3 was achieved after direct stenting (95.1% vs. 93.3%, p = 0.74) without significant difference in the corrected TIMI frame count (31.5 +/- 17 and 35.2 +/- 20 frames after direct and conventional stent, respectively, p = 0.42). The composite angiographic end point was significantly reduced by direct stent implantation (11.7% vs. 26.9%, p = 0.01). ST-segment resolution was also significantly improved after direct stent (no ST-segment resolution in 20.2% vs. 38.1% after direct and conventional stent, respectively, p = 0.01). Death and/or recurrent infarction occurred in six patients after conventional stent implantation and in two patients after direct stenting (p = 0.28).
  
  
  CONCLUSIONS
  In selected patients with AMI, direct stenting can be applied safely and effectively. This strategy may result in a significant reduction of microvascular injury, as suggested by improved ST-segment resolution after reperfusion with major potential clinical consequences.
authors.affiliation: Institut Cardiovasculaire Paris Sud, Hôpital Claude Galien, Quincy-sous-Sénart, France. c.loubeyre@icps.com.fr
authors.forename: Christophe
authors.initials: C
authors.lastname: Loubeyre
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Morice
authors.forename: Thierry
authors.initials: T
authors.lastname: Lefèvre
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Piéchaud
authors.forename: Yves
authors.initials: Y
authors.lastname: Louvard
authors.forename: Pierre
authors.initials: P
authors.lastname: Dumas
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D015425:Myocardial Reperfusion; D011446:Prospective Studies; D015607:Stents; D016896:Treatment Outcome