Quality of life after late invasive therapy for occluded arteries.
BACKGROUND
The open-artery hypothesis postulates that late opening of an infarct-related artery after myocardial infarction will improve clinical outcomes. We evaluated the quality-of-life and economic outcomes associated with the use of this strategy.


METHODS
We compared percutaneous coronary intervention (PCI) plus stenting with medical therapy alone in high-risk patients in stable condition who had a totally occluded infarct-related artery 3 to 28 days after myocardial infarction. In 951 patients (44% of those eligible), we assessed quality of life by means of a battery of tests that included two principal outcome measures, the Duke Activity Status Index (DASI) (which measures cardiac physical function on a scale from 0 to 58, with higher scores indicating better function) and the Medical Outcomes Study 36-Item Short-Form Mental Health Inventory 5 (which measures psychological well-being). Structured quality-of-life interviews were performed at baseline and at 4, 12, and 24 months. Costs of treatment were assessed for 458 of 469 patients in the United States (98%), and 2-year cost-effectiveness was estimated.


RESULTS
At 4 months, the medical-therapy group, as compared with the PCI group, had a clinically marginal decrease of 3.4 points in the DASI score (P=0.007). At 1 and 2 years, the differences were smaller. No significant differences in psychological well-being were observed. For the 469 patients in the United States, cumulative 2-year costs were approximately $7,000 higher in the PCI group (P<0.001), and the quality-adjusted survival was marginally longer in the medical-therapy group.


CONCLUSIONS
PCI was associated with a marginal advantage in cardiac physical function at 4 months but not thereafter. At 2 years, medical therapy remained significantly less expensive than routine PCI and was associated with marginally longer quality-adjusted survival. (ClinicalTrials.gov number, NCT00004562.)
Mark
Daniel B
DB
Outcomes Research Group, Duke Clinical Research Institute, and the Department of Medicine, Duke University Medical Center, Durham, NC, USA.
Pan
Wenqin
W
Clapp-Channing
Nancy E
NE
Anstrom
Kevin J
KJ
Ross
John R
JR
Fox
Rebecca S
RS
Devlin
Gerard P
GP
Martin
C Edwin
CE
Adlbrecht
Christopher
C
Cowper
Patricia A
PA
Ray
Linda Davidson
LD
Cohen
Eric A
EA
Lamas
Gervasio A
GA
Hochman
Judith S
JS
D000203:Activities of Daily Living; D000368:Aged; D000787:Angina Pectoris / Q000453:epidemiology; D015906:Angioplasty, Balloon, Coronary / Q000191:economics; D003131:Combined Modality Therapy; D023921:Coronary Stenosis / Q000188:drug therapy* / Q000628:therapy*; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D012044:Regression Analysis; D015607:Stents; D016896:Treatment Outcome