Does preventive percutaneous coronary intervention of noninfarct but stenosed arteries improve outcomes in patients with acute ST-segment elevation myocardial infarction?
Preventive percutaneous coronary intervention (PCI) of noninfarct, stenosed arteries duing treatment for acute ST-segment elevation myocardial infarction (STEMI) is effective in decreasing long-term cardiovascular events. You would need to treat 7 patients with preventive PCI to avoid one such event. (LOE = 1b)
Wald DS, Morris JK, Wald NJ, et al, for the PRAMI Investigators. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med 2013;369(12):1115-1123.
Randomized controlled trial (single-blinded)
Inpatient (any location) with outpatient follow-up
This study enrolled 465 patients with acute STEMI who received successful PCI to the infarct artery and were noted to have stenosis greater than 50% in other noninfarct coronary arteries during angiography. Patients with history of, or indications for, coronary artery bypass grafting and those in cardiogenic shock were excluded. Using concealed allocation, the investigators randomized patients to receive no further PCI or immediate preventive PCI to noninfarct arteries. The 2 groups had similar comorbidities and a mean age of 62 years. The use of drug-eluting stents and medical therapy after discharge were also similar between groups. The primary outcome was the composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina. Mean follow-up was 2 years and analysis was by intention to treat. The trial was stopped early because of highly significant results favoring preventive PCI. Overall, there was a 9% event rate in the preventive PCI group as compared with 23% in the other group (hazard ratio = 0.35; 95% CI, 0.21-0.58; P < .001). The individual components of the primary outcome showed similar results, although the reduction in cardiac death was not statistically significant (P = .07). As expected, the procedure time and contrast volume used were higher in the preventive PCI group, but the complication rates, including contrast-induced nephropathy, did not differ between groups.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.