Journal Club 1: The Prami Trial


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Journal Club 1: The Prami Trial

  1. 1. The PRAMI Trial Randomized Trial of Preventive Angioplasty in Myocardial Infarction (PRAMI Trial) N Engl J Med 2013; 369:1115-1123
  2. 2. The idea is to present an important recent trial in relation to a  Clinical vignette including relevant images  Brief description of the trial  Single slide highlighting the most important findings of the trial  Relevant clinical guidelines and relationship of the trial to the guideline  Viewer comment opportunity
  3. 3. Clinical Vignette A 65 year old woman with a history of hypertension and hyperlipidemia presents to the ED with 3 hours of acute precordial chest pressure and nausea. He has not past cardiac history and no history of MI. The ECG in the Emergency Department shows anterior ST elevations diagnostic of anterior ST elevation MI. She experiences a witnessed VF arrest in the ED and is defibrillated. His cardiac exam is normal. A STEMI alert is called and the patient moves immediately to the cardiac catheterization laboratory where coronary angiography is performed from the right radial artery. An severely stenosed LAD has partial reperfusion with heparin, aspirin, and ticagrelor and is treated with a drug eluting stent. A significant circumflex lesion is observed and is not considered to be an infarct artery. Should the circumflex be evaluated with FFR and treated at the same time as the STEMI, or should the procedure be deferred. Should FFR of the circumflex artery be performed but an intervention deferred in the acute setting?
  4. 4. ECG on Presentation
  5. 5. Coronary Angiography
  6. 6. The PRAMI Trial The PRAMI Trial Methods: 465 patients with acute STEMI treated with infarct-artery PCI were randomized to either preventive PCI (PCI done immediately - 234 patients) or no preventive PCI (231 patients). Following the acute intervention, subsequent intervention was recommended only if the patient had refractory angina AND objective evidence of ischemia. The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina. Results: The primary outcome occurred in 21 (9%) patients assigned to preventive PCI and in 53 (23%) patients assigned to no preventive PCI during 23 months of follow-up, (hazard ratio, 0.35; 95% confidence interval, 0.21 to 0.58; P<0.001). The corresponding hazard ratios for each of the 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. Conclusion: The authors concluded that in patients with STEMI and significant coronary artery disease in the non-infarct artery, that treatment of the non-infarct-artery with PCI significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery.
  7. 7. Results: The PRAMI Trial (slide will need copyright approval or modification)
  8. 8. Associated Clinical Guidelines (2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary. Circulation. 2013;127:529-555 3.1. Primary PCI in STEMI Class III: Harm PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable.58–60 (Level of Evidence: B) 5.3. PCI of a Noninfarct Artery Before Hospital Discharge Class I PCI is indicated in a noninfarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial infarction (Level of Evidence C) Class IIa PCI is reasonable in a non-infarct artery at a time separate from primary PCI in patients with intermediate or high-risk findings on noninvasive testing (Level of Evidence B)
  9. 9. Survey Question Optimal management of this patient with anterior STEMI treated immediately with an LAD stent would include: A. Stent the circumflex at the same setting based on angiographic assessment. B. Perform FFR of the circumflex, but delay any intervention even in the FFR is less than 0.75. C. Perform FFR of the circumflex and stent at the same setting if the FFR is less than 0.75. D. Plan “staged” stenting of the circumflex artery during the same admission E. Perform non-invasive evaluation of the circumflex with exercise testing and treat only if significant ischemia is present.