"Preventive Angioplasty in Acute Myocardial Infarction (PRAMI)". The New England Journal of Medicine. 2013.
Links to original sources: Wiki Journal Post Full Journal Article
Does performing preventive percutaneous coronary intervention (PCI) in noninfarct arteries during emergency myocardial infarction (MI) PCI reduce adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease?
Preventive PCI in noninfarct arteries with significant stenosis during primary PCI for STEMI significantly reduces the risk of future adverse cardiovascular events compared to treating the infarct artery alone.
The PRAMI study found that in patients with STEMI undergoing PCI for the infarct-related artery, additional preventive PCI in noninfarct coronary arteries with major stenoses significantly reduced rates of death from cardiac causes, nonfatal MI, and refractory angina, compared with no additional PCI.
Current guidelines recommend PCI of the infarct artery only in STEMI patients with multivessel disease, owing to previous lack of evidence regarding the value of preventive PCI.
PRAMI was a multicenter, single-blind, randomized controlled trial conducted from April 2008 through January 2013. The trial was prematurely stopped based on recommendations due to a significant reduction in primary outcome events favoring preventive PCI.
The trial enrolled 465 patients with acute STEMI and multivessel coronary disease detected at the time of emergency PCI for the infarct artery.
Inclusion Criteria: - Acute STEMI, including three patients with left bundle-branch block - Successful PCI treatment of the infarct artery - Stenosis of ≥50% in other coronary arteries treatable by PCI
Exclusion Criteria: - Cardiogenic shock - Previous coronary-artery bypass grafting - Ineligibility due to other specified concerns
Patients were randomized to receive either no further PCI procedures after the infarct-artery PCI (n=231) or to undergo immediate preventive PCI in noninfarct arteries with >50% stenoses (n=234).
The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina.
Primary outcomes occurred in 21 patients in the preventive-PCI group and 53 in the infarct-artery-only PCI group, revealing a significant hazard ratio of 0.35 in favor of preventive PCI. Hazard ratios for death from cardiac causes, nonfatal MI, and refractory angina were also in favor of preventive PCI.
The study did not address whether the benefits of preventive PCI extend to patients with non-STEMI or whether immediate or delayed (staged) preventive PCI is superior.
Supported by Barts and the London Charity.
The article was published on September 1, 2013, at NEJM.org.