Preventive PCI results in better outcomes than culprit artery PCI alone in ST elevation MI

September 01, 2013

AMSTERDAM, The Netherlands - Heart attack patients with ST elevation who undergo a preventive procedure to unblock additional coronary arteries have significantly better outcomes than those whose treatment is confined to the culprit blockage only, according to the results of the Preventive Angioplasty in Myocardial Infarction (PRAMI) Trial.

The findings, presented today at the ESC and published simultaneously in the New England Journal of Medicine, provide information that will help guide clinical practice and resolve uncertainty over how to approach percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (MI).

"When a patient is admitted with an acute myocardial infarction, it is known that PCI to the blocked culprit artery is life-saving, but there is uncertainty as to whether doctors should undertake preventive PCI in vessels that are partially blocked but did not cause the myocardial infarction. This is a common clinical dilemma," said the study's lead investigator David Wald, MD, from the Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine, Queen Mary University of London and the London Chest Hospital.

The PRAMI trial was stopped early by the Data Monitoring Committee when a planned interim analysis showed a clear benefit in favor of preventive PCI that was evident within 6 months of the procedure and maintained thereafter.

"The results of this trial show that in this situation preventive PCI, in this situation, reduces the risk of cardiac death, a subsequent myocardial infarction or angina resistant to medical therapy, by about two-thirds."

With this new evidence, "consideration can be given to revising current guidelines," he added.

Current guidelines recommend culprit-only PCI for patients with ST elevation myocardial infarction and multivessel disease, because until now there was a lack of evidence in favor of preventive PCI.

In the trial, patients undergoing emergency PCI for acute ST elevation (462) or left bundle branch block (3) myocardial infarction and multivessel coronary artery disease were randomized while in the catheterization laboratory to either preventive PCI (234), or culprit-only PCI (231).

Patients were eligible for the preventive procedure if their culprit artery had been treated successfully and they had a blockage (stenosis) of 50% or more that was treatable by PCI in another or several other coronary arteries.

After a mean follow-up of 23 months (67% of patients had at least one year, and 46% at least 2 years, of follow-up) a total of 21 patients in the preventive PCI group and 53 in the culprit-only group had experienced a primary outcome event (cardiac death, nonfatal myocardial infarction or refractory angina) showing an absolute risk reduction of 14 per hundred patients in the preventive PCI group [hazard ratio 0.35 (95% CI 0.21-0.58), p<0.001], and a relative risk reduction of 65%.

The rate of complications was similar in the preventive and culprit-only PCI groups (procedure related stroke 2 vs 0; bleeding requiring transfusion or surgery, 7 vs 6; and contrast-induced nephropathy requiring dialysis, 1 vs 3).

Procedure time, fluoroscopy dose and contrast volume were increased in the preventive PCI group (median 63 vs 45 minutes, median 90.1 vs 71.4 Gycm2, and median 300 vs 200 mL).

"The results show that on average, preventive PCI extends the procedure time by about 20 minutes, uses an extra 100mls of contrast (the dye used in angiography) and exposes the patient to an X-ray dose equivalent to an angiogram," said Dr. Wald, adding that" the initial costs of preventive PCI are higher but there will be reduced costs thereafter, with a reduced need for subsequent hospital admissions, cardiac investigations and revascularisation procedures."
-end-
(Wald DS, Morris JK, Wald NJ, Chase AJ, Edwards RJ, Hughes LO, Berry C, Oldroyd KG. Randomized Trial of reventive Angioplasty in Myocardial Infarction. New England Journal of Medicine 2013

FUNDING: Barts and London Charity; ISRCTN number, 73028481

DISCLOSURES: None

Notes to editor

About the European Society of Cardiology

The European Society of Cardiology (ESC) represents more than 80 000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.

About ESC Congress 2013

The ESC Congress is currently the world's premier conference on the science, management and prevention of cardiovascular disease. The spotlight of this year's event is "The Heart Interacting with Systemic Organs". ESC Congress 2013 takes place from 31 August to 4 September at the RAI centre in Amsterdam, Netherlands. More information is available from the ESC Press Office at press@escardio.org

European Society of Cardiology

Related Cardiac Death Articles from Brightsurf:

Sudden cardiac death often a woman's first sign of heart disease
New research from the Center for Cardiac Arrest Prevention at the Smidt Heart Institute at Cedars-Sinai shows that rates of sudden cardiac arrest are rising following decades of a downward trend.

New research could reduce the risk of sudden cardiac death
New research has shown that by changing the time course of voltage change early in action potential it is possible to both withhold a potentially lethal electrical disturbance and improve the strength of cardiac contraction in heart failure at the same time.

Rare genetic variants predispose to sudden cardiac death
By identifying rare DNA variants that substantially increase risk of sudden cardiac death, researchers have laid the foundation for efforts to identify individuals who could benefit from prevention strategies prior to experiencing symptoms.

Study: Cholesterol in eggs tied to cardiac disease, death
The risk of heart disease and death increases with the number of eggs an individual consumes, according to a UMass Lowell nutrition expert who has studied the issue.

New tool better at predicting death after cardiac admission than current indexes
A new tool designed for patients with heart disease is better at predicting death after hospital admission than current tools, according to a study published in CMAJ (Canadian Medical Association Journal).

PTSD linked to increased complications and death a year after cardiac arrest
Post-traumatic stress disorder (PTSD) symptoms may significantly increase cardiac arrest survivors' risk of major cardiovascular events and death up to a year after the initial medical crisis, according to preliminary research to be presented in Chicago at the American Heart Association's Resuscitation Science Symposium 2018 -- an international conference highlighting the best in cardiovascular resuscitation research.

Preventing sudden cardiac death with genome editing
Gene editing successfully prevented sudden cardiac death in a mouse model of inherited cardiac arrhythmia disorder.

Wearable defibrillator lowers sudden cardiac death, but only when you wear it
An international clinical trial that studied wearable cardioverter defibrillators (WCDs) found that the devices did not significantly reduce sudden cardiac death -- the primary goal of the device -- among patients assigned to the device in the first 90 days after a heart attack, but did lower mortality among those who wore it as prescribed, according to a study led by researchers at UC San Francisco.

Blood thinner significantly reduces the risk of death after non-cardiac surgery
The study enrolled 1,754 patients in 19 countries, 51 percent of whom were male, with an average age of 70 years.

New model estimates odds of events that trigger sudden cardiac death
A new computational model of heart tissue allows researchers to estimate the probability of rare heartbeat irregularities that can cause sudden cardiac death.

Read More: Cardiac Death News and Cardiac Death Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.