Preventive Angioplasty In Myocardial Infarction Research Articles

Complete Immediate Revascularization of the Patient With ST-Segment-Elevation Myocardial Infarction Is the New Standard of Care.

Opposing Viewpoint, see p 1574 Approximately half of patients with ST-segment–elevation myocardial infarction (STEMI) have angiographically significant multivessel disease and, in these patients, the European (2012) and US (2013) guideline recommendations have been that only the culprit artery should be treated acutely. In the setting of cardiogenic shock, the guidelines recommend treating any nonculprit arteries to achieve as complete a revascularization as possible. Both of these recommended strategies are based on level C evidence (observational studies and consensus opinion). In the past 4 years, there have been 3 new randomized trials that have contributed to the knowledge base in this area (Table). View this table: Table. Contemporary Randomized Controlled Trials of Culprit-Only Percutaneous Coronary Intervention Versus Complete Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction The PRAMI trial (Preventive Angioplasty in Myocardial Infarction) was a UK-based multicenter randomized trial of culprit only percutaneous coronary intervention (PCI) in comparison with immediate complete revascularization. On the recommendation of the data safety and monitoring board, recruitment to the PRAMI trial was halted in January 2013, after 465 patients had been randomly assigned. After an average of 2 years follow-up, the relative risk reduction in the primary end point of cardiovascular death, nonfatal myocardial infarction (MI), and refractory ischemia in patients randomly assigned to complete revascularization was 65% ( P <0.001), more than double that estimated in the original power calculation. The between-group difference in the secondary end point of cardiovascular death and nonfatal MI remained statistically significant ( P <0.001).1 The CvLPRIT (Complete versus Lesion-only Primary …

The Impact of the ‘PRAMI’ Trial on Interventional Practice in Patients with ST Elevation Myocardial Infarction at a University Hospital

Background: Randomized controlled trials, notably PRAMI (Randomized trial of preventive angioplasty in myocardial infarction) demonstrated that immediate percutaneous coronary intervention (PCI) in significantly stenosed non-culprit vessels in patients with ST elevation myocardial infarction (STEMI) reduces adverse outcomes. However, the impact on clinical practice is unknown. Aims: To investigate whether the number of immediate and staged non-culprit PCIs has changed after the publication of PRAMI and the impact on mortality. Methods: A retrospective analysis of STEMI patients with significant multi-vessel disease presenting 1 year before and after PRAMI were included. Patients were divided into those who had immediate PCI, staged PCI or medical management of the non-culprit vessel. Mortality data for each patient group was analyzed. Results: Significant multi-vessel disease was present in 426 patients, with 202 patients in the pre-PRAMI group and 224 in the post-PRAMI group. The number of immediate non-culprit PCIs pre- PRAMI was 9.4% and increased to 12.5% post- PRAMI [p=ns]. Combining both groups, immediate PCI of the non-culprit vessel was associated with higher mortality than staged PCI [p=0.005]. There was no significant difference in all cause mortality in patients having non-culprit vessel PCI (immediate or staged) when compared to the medically managed cohort. Conclusion: Our center demonstrated a trend towards increased immediate PCI of the non-culprit vessel during the index procedure however, this practice was not widely adopted as recommended by PRAMI. Immediate PCI of non- culprit vessels was associated with increased mortality compared with staged PCI or medical management. However, given the small number of patients undergoing Immediate PCI, larger trials are required to confirm our results.

Stenting the Non-Culprit Lesion during Primary Angioplasty of the Infarct-Related Coronary Artery: The Long and Winding Road

Submit Manuscript | http://medcraveonline.com J Cardiol Curr Res 2015, 4(3): 00141 treatment of choice for ST-segment elevation myocardial infarction (STEMI) [3]. Considering the fact that patients with multivessel coronary heart disease (CHD) comprise over half of the STEMI population, it is not an uncommon finding to observe a significant non-culprit lesion besides the occluded infarctrelated coronary artery during primary PCI. These patients with multivessel disease in this context have a worse prognosis than patients with single vessel disease [4,5]. Now, the problem is what to do with the non-culprit significant stenosis once the infarctrelated coronary artery was already treated. Should we proceed and stent the non-culprit lesion turning unstable a coronary plaque that was previously stable and jeopardize another wall in a patient that already has an infarcted territory? It seems logical to think that treating all significant coronary stenosis would provide a better clinical outcome. However, although there is recent data in favor of this therapeutic management, the 2013 ACCF/ AHA guidelines for the management of ST-elevation myocardial infarction discouraged this approach due to a significant increase in adverse outcomes for patients undergoing multivessel PCI in the setting of STEMI, and recommended a restrictive approach that discourages treatment of non-culprit lesions during the index PCI, unless the patient is in cardiogenic shock [6]. Moreover, the 2014 ESC/EACTS guidelines on myocardial revascularization are in accordance with the latter approach [7]. They stated that evidence supporting immediate (preventive) intervention in noninfarct-related lesions is a matter of debate [8,9]. On the other hand, patients with extensive CHD in vessels remote from the infarct-related artery have reduced success in reperfusion and an adverse prognosis following primary PCI [8]. They concluded that at present, multivessel PCI during STEMI should be considered in patients with cardiogenic shock in the presence of multiple, critical coronary stenosis, and if there is persistent ischemia after PCI on the supposed culprit lesion [6]. It is well known that patients with stable CHD and multivessel disease benefit from achieving complete revascularization [1013]. The question is if this assumption also holds true in the setting of STEMI if a more aggressive approach leading to more complete revascularization is performed. This is a controversial subject if we analyze current data based on observational studies and compare them to the results of recent randomized clinical trials in the era of drug eluting stents. In fact, observational data suggested that this approach was not beneficial and might be even harmful, with slightly better outcome depending on the timing of the nonculprit PCI [14,15]. On the other hand, recent evidence obtained from randomized trials documented significant reductions in composite ischemic endpoints by performing multivessel revascularization during STEMI [16,17]. However, there had been some inconsistencies in the analysis of the results. For example, the PRAMI (Preventive Angioplasty in Myocardial Infarction) trial [16], was stopped prematurely due to a much higher than expected treatment efficacy. They found a 65% reduction in ischemic events with complete revascularization during the index PCI in 465 patients. It seems a little surprising to achieve such high statistically significant results with a relatively small number of patients and of clinical events raising concerns of a chance finding magnified by the early termination of the trial. In addition, the CVLPRIT (Complete Versus Lesion-Only Primary PCI) trial [17] did not show reductions in hard endpoints, and the benefit demonstrated in the composite endpoint was obtained by repeat revascularizations. This open-label clinical trial randomized 296 patients in 7 UK centers to either inhospital complete revascularization (n: 150), or culprit lesiononly revascularization (n: 146). Complete revascularization was performed in the index hospitalization either at the time of primary PCI or before hospital discharge. The primary endpoint of mortality, recurrent myocardial infarction, heart failure, or ischemia-driven revascularization within 12 months occurred in Editorial

109 Left Ventricular Outcomes Following Multivessel PCI Vs. Infarct -Only PCI in Patients with Acute Stemi: The Glasgow Prami CMR Sub-Study: Abstract 109 Table 1

Background In the Randomised Trial of Preventive Angioplasty in Myocardial Infarction (PRAMI; ISRCTN73028481), compared with infarct-related artery (IRA)-only PCI, additional immediate multivessel PCI (MV-PCI) of non-IRA lesions in patients with acute ST elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) improved long term prognosis. We studied left ventricular (LV) outcomes in a pre-specified cardiac magnetic resonance (CMR) sub-study. Methods In a single centre prospective sub-study, PRAMI participants were invited to undergo CMR at 1.5 Tesla 1 week and 1 year after primary PCI. LV volumes and function were analysed using semi-automated software by a clinician blinded to treatment group assignment and clinical outcomes. The statistical analyses were performed by an independent statistician. Results Of 465 randomised trial participants in 6 UK hospitals, 138 (30%) were enrolled in Glasgow. Eighty patients (17%) (mean age 60 years, 76% male) underwent CMR initially (n = 41 (51%) in the multi-vessel PCI group; n = 39 (49%) in the IRA-only group). 69 (86%) of these patients had a follow up CMR scan at 1 year (n = 7 lost to follow-up, n = 4 deceased). Mean (and SD) LVEF and volumes at 1 week post-MI and their change at 1 year from baseline were similar (Table 1). Conclusion The CMR sub-study participants represented the majority of all randomised participants in our hospital, which included one third of the PRAMI trial population. Random treatment group assignment in this CMR study was evenly balanced. LV function and volumes were similar at 1 week and 1 year post-intervention in survivors. The CMR sub-study suggests that the benefit of the preventive PCI strategy in PRAMI may not be mediated by any effects on LV function and remodelling. Funding Golden Jubilee National Hospital; PRAMI was funded by Barts and the London Charity.

LEFT VENTRICULAR OUTCOMES FOLLOWING MULTIVESSEL PCI VERSUS INFARCT-ONLY PCI IN PATIENTS WITH ACUTE STEMI: THE GLASGOW PRAMI CMR SUB-STUDY

In the Randomized Trial of Preventive Angioplasty in Myocardial Infarction (PRAMI; [ISRCTN73028481][1]), compared with infarct-related artery (IRA)-only PCI, additional immediate multivessel PCI (MV-PCI) of non-IRA improved long term prognosis. We studied left ventricular (LV) outcomes in a pre-

Left ventricular outcomes following multivessel PCI vs. infarct artery-only PCI in patients with acute STEMI: the Glasgow PRAMI CMR sub-study

Background In the Randomised Trial of Preventive Angioplasty in Myocardial Infarction (PRAMI; ISRCTN73028481), compared with infarct-related artery (IRA)-only PCI, additional immediate multivessel PCI (MV-PCI) of non-IRA lesions in patients with acute ST elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) improved long term prognosis. We studied left ventricular (LV) outcomes in a pre-specified cardiac magnetic resonance (CMR) sub-study. Methods In a single centre prospective sub-study, PRAMI participants were invited to undergo CMR at 1.5 Tesla 1 week and 1 year after primary PCI. LV volumes and function were analysed using semi-automated software by a clinician blinded to treatment group assignment and clinical outcomes. The statistical analyses were performed by an independent statistician. Results Of 465 randomised trial participants in 6 UK hospitals, 138 (30%) were enrolled in Glasgow. Eighty patients (17%) (mean age 60 years, 76% male) underwent CMR initially (n = 41 (51%) in the multi-vessel PCI group; n = 39 (49%) in the IRA-only group). 69 (86%) of these patients had a follow up CMR scan at 1 year (n = 7 lost to follow-up, n = 4 deceased). Mean (and SD) LVEF and volumes at 1 week post-MI and their change at 1 year from baseline were similar (Table 1). Conclusion The CMR sub-study participants represented the majority of all randomised participants in our hospital, which included one third of the PRAMI trial population. Random treatment group assignment in this CMR study was evenly balanced. LV function and volumes were similar at 1 week and 1 year post-intervention in survivors. The CMR sub-study suggests that the benefit of the preventive PCI strategy in PRAMI may not be mediated by any effects on LV function and remodelling. Funding Golden Jubilee National Hospital; PRAMI was funded by Barts and the London Charity.

Preventive angioplasty in myocardial infarction.

Preventive angioplasty in myocardial infarction.

Preventive angioplasty in myocardial infarction.

Preventive angioplasty in myocardial infarction.

Preventive angioplasty in ST-segment elevation myocardial infarction

To the EditorWereadwithgreatinterest,arecentrandomizedtrialinBritishpop-ulation by Wald et al. [1] titled “Randomized Trial of Preventive Angio-plasty in Myocardial Infarction (PRAMI trial)” published on September19, 2013 in “New England Journal of Medicine”.PatientswithST-segment elevation myocardial infarction were randomly assigned toeither “preventive percutaneous coronary intervention” (PCI) or “nopreventive PCI” arm soon after they underwent infarct-artery PCI. Wehave the following comments on their randomized study. PreventivePCI was performed on lesions with stenosis ≥50%. However, theAmerican College of Cardiology and the American Heart Associationconsider lesions with stenosis ≥70% as significant [2]. Furthermore,Fractional Flow Reserve Versus Angiography in Multivessel Evaluation(FAME) study [3] showed that only a third of lesions with 50–70% ste-nosis are functionally significant, in comparison to over 80% of lesionswith stenosis N70%.Hence,wehypothesizethatreducedriskofadverseoutcomes in thepreventive-PCI arm wasprimarily dueto PCI of lesionswith stenosis ≥70%. Authors should have assessed for the risk of ad-verse outcomes after categorizing the preventive-PCI arm according totheseverityoflesions(50–70%vs. ≥70%stenosis),toseeifthefavorableoutcomeswerepredominantly in participants with ≥70% stenosis.Thiscan potentially help in curtailing healthcare costs by avoiding unneces-sary PCI for coronary lesions with 50–70% stenosis.Participantsin “NoPreventive-PCI”armdidnotgetPCIuntiltheypre-sented with refractory angina, even if they had severe stenosis at thetime of randomization. However, ideally patients with noninfarct arterylesionsshouldundergostagedPCIiffoundtohaveintermediate-orhigh-riskfeatures onnon-invasive testing [4], and not wait until one becomessymptomatic.This bringstothefore the denialof standard of care inthispatient subgroup.Furthermore, although baseline characteristics of the “Preventive-PCI” and “No Preventive-PCI” arm look fairly similar, authors haveexcluded the vital information regarding the infarct-artery door-to-balloon times. Prolonged door-to-balloon-times are associated withhigher long-term mortality [5]. If the mean door-balloon-time was sig-nificantlydifferentbetweenthetwoarms,itcouldhaveeasilyin fluencedmortality data, thereby either overestimating or underestimating themortality benefit in the preventive-PCI group.References

PCI in noninfarction arteries reduced cardiac events in acute STEMI with multivessel coronary disease

ACP Journal ClubDecember 17, 2013PCI in noninfarction arteries reduced cardiac events in acute STEMI with multivessel coronary diseaseRichard Brown, MBBS, Gregory Y.H. Lip, MDRichard Brown, MBBSUniversity of Birmingham Centre for Cardiovascular Sciences, Birmingham, England, UK (R.B., G.Y.L.)Search for more papers by this author, Gregory Y.H. Lip, MDUniversity of Birmingham Centre for Cardiovascular Sciences, Birmingham, England, UK (R.B., G.Y.L.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-159-12-201312170-02003 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source CitationWald DS, Morris JK, Wald NJ, et al; PRAMI Investigators. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115-23. https://pubmed.ncbi.nlm.nih.gov/23991625Clinical Impact RatingsCardiology: References1 Jensen LO, Thayssen P, Farkas DK, et al. Culprit only or multivessel percutaneous coronary interventions in patients with ST-segment elevation myocardial infarction and multivessel disease. EuroIntervention. 2012;8:456-64. [PMID: 22917729] Google Scholar2 Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. 2008;117:686-97. [PMID: 18250279] Google Scholar3 Task Force on the Management of ST-segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC), Steg PG, James SK, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569-619. [PMID: 22922416] Google Scholar4 Mylotte D, Morice MC, Eltchaninoff H, et al. Primary percutaneous coronary intervention in patients with acute myocardial infarction, resuscitated cardiac arrest, and cardiogenic shock: the role of primary multivessel revascularization. JACC Cardiovasc Interv. 2013;6:115-25. [PMID: 23352816] Google Scholar Author, Article, and Disclosure InformationAffiliations: University of Birmingham Centre for Cardiovascular Sciences, Birmingham, England, UK (R.B., G.Y.L.) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics December 17, 2013Volume 159, Issue 12Page: JC3KeywordsAnginaAngioplastyArteriesConvalescenceCoronary arteriesCoronary artery bypass graftingFatigueForecastingHeartHeart diseasesInfarctionLesionsMyocardial infarctionPercutaneous coronary interventionSafetySafety studiesStable coronary artery diseaseStenosis Issue Published: December 17, 2013 Copyright & PermissionsCopyright © 2013 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Randomized Trial of Preventive Angioplasty in Myocardial Infarction

BackgroundIn acute ST-segment elevation myocardial infarction (STEMI), the use of percutaneous coronary intervention (PCI) to treat the artery responsible for the infarct (infarct, or culprit, artery) improves prognosis. The value of PCI in noninfarct coronary arteries with major stenoses (preventive PCI) is unknown.MethodsFrom 2008 through 2013, at five centers in the United Kingdom, we enrolled 465 patients with acute STEMI (including 3 patients with left bundle-branch block) who were undergoing infarct-artery PCI and randomly assigned them to either preventive PCI (234 patients) or no preventive PCI (231 patients). Subsequent PCI for angina was recommended only for refractory angina with objective evidence of ischemia. The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina. An intention-to-treat analysis was used.ResultsBy January 2013, the results were considered conclusive by the data and safety monitoring committee, which recommended that the trial be stopped early. During a mean follow-up of 23 months, the primary outcome occurred in 21 patients assigned to preventive PCI and in 53 patients assigned to no preventive PCI (infarct-artery-only PCI), which translated into rates of 9 events per 100 patients and 23 per 100, respectively (hazard ratio in the preventive-PCI group, 0.35; 95% confidence interval [CI], 0.21 to 0.58; P<0.001). Hazard ratios for the three components of the primary outcome were 0.34 (95% CI, 0.11 to 1.08) for death from cardiac causes, 0.32 (95% CI, 0.13 to 0.75) for nonfatal myocardial infarction, and 0.35 (95% CI, 0.18 to 0.69) for refractory angina.ConclusionsIn patients with STEMI and multivessel coronary artery disease undergoing infarct-artery PCI, preventive PCI in noninfarct coronary arteries with major stenoses significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery. (Funded by Barts and the London Charity; PRAMI Current Controlled Trials number, ISRCTN73028481.)

European Society of Cardiology (ESC) Congress Report From Amsterdam 2013

The Annual Congress of the European Society of Cardiology (ESC) was held in Amsterdam from the 31(st) of August to the 4(th) of September 2013. The total attendance up to the 3(rd) was 29,990. Several important topics were presented and discussed, including a randomized trial of preventive angioplasty in myocardial infarction (PRAMI), transcatheter aortic valve implantation, renal denervation, management of vasospastic angina, plaque vulnerability and outcome assessed by OCT and diuretic resistance in heart failure (an ESC-JCS [Japanese Circulation Society] joint session), and OCT-guided percutaneous coronary intervention. The ESC congress has become one of the most important and attractive international scientific meetings. Importantly, Japan topped the number of abstracts submitted (1,459 abstracts) and accepted (565 abstracts) to ESC 2013. Thus, the ESC is eager to continue the strong collaboration with the JCS as the relationship between them gets closer year by year.