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.