Original title: Randomized Trial of Preventive Angioplasty in Myocardial Infarction (PRAMI trial). Referencia: David S. Wald et al. N Engl J Med 2013.DOI: 10.1056/NEJMoa1305520.
Patients developing ST segment elevation myocardial infarction are effectively treated with primary angioplasty to responsible artery . It is unclear whether revascularized other significant lesions in other non culprit vessels will prevent future events and in fact, guides advise against it except when we are in the context of shock. The aim of this single-blind randomized trial was to evaluate whether practice preventive angioplasty in other injuries as part of primary angioplasty over the responsible artery may decrease the composite of cardiac death , myocardial infarction or refractory angina.
Between 2008 and 2013, 465 patients suffering ST segment elevation myocardial infarction were successfully treated for the responsible artery and that also had other lesions ≥ 50 % possibility of revascularization added for hemodynamic stability ( we excluded patients with left main coronary artery injury, chronic total occlusions and cardiogenic shock ) . Once primary angioplasty was completed we randomized remaining lesions to immediate preventive angioplasty or terminate the procedure. Angioplasty in stages was discouraged and the only reason to revascularize non culprit injuries in the control branch was refractory angina with demonstrated ischemia. On January 24th, 2013 the trial was stopped early for the recommendation of the safety committee given the significant difference in the primary end point for the preventive angioplasty branch .
At the end of the study per mean of 23 months, the primary endpoint ( combined cardiac death, myocardial infarction and refractory angina ) was observed in 21 of 234 patients in the preventive angioplasty branch versus 53 of 231 patients in the control branch ( RR 0.35 , CI 0.21 to 0.58 , p < 0.001). The effect was similar in magnitude and highly significant when performing the analysis considering only cardiac death and myocardial infarction ( RR 0.36 , CI 0.18 to 0.73 , P = 0.004 ) .
Conclusion:
In this randomized trial, we observed that after successful primary angioplasty , perform the same procedure concomitantly of preventive angioplasty to other arteries with significant lesions but not responsible for the heart attack reduces adverse cardiovascular event risk compared with single angioplasty limited to the responsible artery.
Editorial Comment
This study does not answer the question about deferred angioplasty (a common practice in many centers ), where primary angioplasty is performed only in the culprit artery but in the same placement ( 48-72 hours later) completes the non culprit vessel revascularization. In this sense protocol was very rigid allowing angioplasty to other vessels in the control branch only in the context of refractory angina and ischemia determined .
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