Preventive angioplasty in myocardial infarction trial
The Preventive Angioplasty in Myocardial Infarction (PRAMI) Trial is a randomised trial comparing two strategies for treating patients with an acute heart attack:
• therapeutic angioplasty (treatment to unblock only the artery causing the heart attack);
• therapeutic plus preventive angioplasty (additional angioplasty to treat other arteries that are found to be narrowed but were not the cause of the heart attack).
Patients who suffer a heart attack are best treated by angioplasty, a procedure in which narrow tubes are fed up to the heart from arteries in the leg or arm under x-ray guidance. Steerable guide-wires are used to position expandable stents (cylindrical metal scaffolds) to restore blood flow to the blocked artery causing the heart attack (the culprit artery) - a so-called "therapeutic angioplasty".
During the angioplasty procedure narrowed coronary arteries are often identified that were not the cause of the heart attack. Once the culprit artery has been unblocked, the practice of dilating these other arteries varies from doctor to doctor. Some believe these non-culprit arteries may cause future heart attacks which could be avoided by performing a "preventive angioplasty" as part of the initial procedure. Treating non-culprit arteries, however, carries additional risks to the patient (such as bleeding, stroke and death which may increase by 0.5-1%) and costs more, leading other doctors to take the view that drugs (such as aspirin and cholesterol lowering drugs) are sufficient therapy and that the risk and cost of an extended procedure outweighs the benefits.
Until the results of this trial were known it was uncertain whether routine preventive angioplasty in "non-culprit" arteries reduced the risk of a future cardiac event, to an extent that would justify the higher cost and greater risk that is associated with the extended procedure. This trial has helped to answer this question.
54 year old man with an acute inferior myocardial infarction
Should the left anterior decsending be treated by angioplasty as an extension of the acute procedure, to prevent a future problem (e.g. a heart attack) arising in relation to this artery?
- Preventive Angioplasty, Stenting Decrease Risk of Cardiac-Related Events After MI: Presented at ESC http://www.firstwordmedtech.com/node/957322
- Randomised Trial of Preventive Angioplasty in Myocardial Infarction: http://www.mdlinx.com/medical-student/news-article.cfm/4803247/myocardial-infarction
- Clearing More Arteries Works in Angioplasty Trial: http://www.nlm.nih.gov/medlineplus/news/fullstory_140274.html
- Preventive PCI for patients with ST elevation myocardial infarction results in better outcomes: http://www.news-medical.net/news/20130905/Preventive-PCI-for-patients-with-ST-elevation-myocardial-infarction-results-in-better-outcomes.aspx
- David Wald
- Joan Morris
- Nicholas Wald
- Keith Oldroyd, Glasgow
- Alex Chase, Swansea
- Richard Edwards, Newcastle
- Liam Huges, Norwich
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