In the context of an ST-segment elevation myocardial infarction, primary angioplasty to treat the culprit lesion improves the prognosis. The role of angioplasty in unrelated arteries is not well established.
Between 2008 and 2013, 465 patients with myocardial infarction underwent primary angioplasty and were randomized to preventive (234 patients) vs non-preventive angioplasty (231 patients). The preventive treatment was defined as treating other arteries with serious lesions as well as the culprit artery in the same procedure. For the non-preventive arm, the other lesions were treated only if the patient presented symptoms or ischemia was observed. The primary end point was a combined death, myocardial infarction and refractory angina.
In January 2013, the results were considered conclusive; hence the safety committee recommended the study be discontinued. In the following 23 months, the primary end point occurred in 21 patients in the preventive angioplasty arm and 53 patients in the non-preventive arm (HR for preventive angioplasty 0.35; 95% CI, 0.21 – 0.58; p<0.001).
Conclusion:
In patients with ST segment elevation myocardial infarction and multiple vessels, the primary angioplasty of the culprit artery in addition to angioplasty of severe but non-culprit lesions significantly reduced the risk of events compared to angioplasty only of the culprit artery.
Editorial comment:
The relative reduction observed of 65% was basically due to the reduced risk of reinfarction and refractory angina. The difference in cardiovascular death was of no statistical significance. It is important to stress that according to the guidelines (ACC/AHA 2013) angioplasty should not be performed on other arteries unless there is hemodynamic compromise.
David Wald
2013-09-02
Original title: PRAMI: Preventive Angioplasty in Myocardial Infarction Trial.