Randomized Trial of Preventive Angioplasty in Myocardial Infarction
What is the impact of performing percutaneous coronary intervention (PCI) on the nonculprit lesion (preventive PCI) at the time of primary PCI in a patient with ST-segment elevation myocardial infarction (STEMI)?
The PRAMI (Preventive Angioplasty in Acute Myocardial Infarction) trial investigators randomized 465 patients with STEMI undergoing primary PCI at five centers in the United Kingdom, from 2008 through 2013. Patients were assigned to either preventive PCI (234 patients) or no preventive PCI (231 patients). Subsequent PCI for angina was recommended only for refractory angina with objective evidence of ischemia. The primary outcome was a composite of death from cardiac causes, nonfatal MI, or refractory angina.
The trial was stopped early at the recommendation of the data and safety monitoring committee. During a mean follow-up of 23 months, preventive PCI was associated with a reduction in the primary outcome (9% vs. 23%; hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.21-0.58; p < 0.001). HRs for the three components of the primary outcome were similar (death from cardiac cause, 0.34 [95% CI, 0.11-1.08]; nonfatal MI, HR, 0.32 [95% CI, 0.13-0.75]; refractory angina, HR, 0.35 [95% CI, 0.18-0.69]).
The authors concluded that preventive PCI is associated with a reduction in major adverse events in patients undergoing primary PCI.
This study provides some welcome evidence to guide treatment of nonculprit lesions in patients with STEMI. Current guidelines argue against preventive PCI during the primary PCI, and according to the area under the curve (AUC), such a practice would be considered inappropriate. It is our practice to treat nonculprit lesions in a staged setting, either during the same hospitalization, or as a semi-elective procedure in 2-4 weeks. This trial provides indirect evidence to support such a practice. The investigators did not test the impact of immediate versus staged preventive PCI, and absent data to the contrary, I do not think a change in our practice is warranted. It is time, however, to consider an amendment to the AUC so that operators who decide to perform preventive PCI are not penalized.
Keywords: Great Britain, Myocardial Infarction, Coronary Angiography, Cardiology, Cardiovascular Diseases, Confidence Intervals, Angioplasty, Balloon, Coronary, Hospitalization, Percutaneous Coronary Intervention
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