Preventive Angioplasty in STEMI

Posted by • September 20th, 2013

Patients with acute STEMI were randomly assigned to undergo infarct-vessel-only PCI or preventive PCI (PCI to noninfarct arteries with stenoses). The rate of the primary outcome of cardiac death, myocardial infarction, or refractory angina was lower with preventive PCI.

Patients with acute STEMI are effectively treated with emergency angioplasty, or PCI, to restore blood flow to the coronary artery that is judged to be causing the myocardial infarction (target artery). These patients may have substantial stenoses in coronary arteries that were not responsible for the myocardial infarction, but the value of performing PCI in such arteries for the prevention of future cardiac events is not known.

Clinical Pearls

• What was the primary outcome of this study of patients with STEMI when target-only PCI was compared to preventive PCI?

The results of this trial show that in patients with acute STEMI, the use of preventive PCI to treat nontarget coronary-artery stenoses immediately after PCI in the target artery had substantial advantage over target-vessel-only PCI. The combined rate of cardiac death, nonfatal myocardial infarction, or refractory angina was reduced by 65%, an absolute risk reduction of 14 percentage points over 23 months.

• When was the risk reduction in the preventive-PCI group realized and how long was it maintained?

The Kaplan-Meier analysis showed that the risk reduction in the preventive-PCI group was evident within 6 months after the procedure and was maintained thereafter.

Figure 2. Kaplan-Meier Curves for the Primary Outcome.

Morning Report Questions

Q: Were there any differences in periprocedural complications between the two groups?

A: The procedural time, fluoroscopy dose, and contrast volume were increased in the preventive-PCI group. The rates of complications (procedure-related stroke, bleeding requiring transfusion or surgery, and contrast-induced nephropathy requiring dialysis) were similar in the two groups (P=0.84).

Q: What are the current guidelines on the management of STEMI?

A: Current guidelines on the management of STEMI recommend target-vessel-only PCI in patients with multivessel disease, owing to a lack of evidence with respect to the value of preventive PCI. According to the authors, this uncertainty has led to variations in practice, with some cardiologists performing immediate preventive PCI in spite of the guidelines, some delaying preventive PCI until recovery from the acute episode, and others limiting the procedure to patients with recurrent symptoms or evidence of ischemia. The authors contend that the results of this trial may help resolve the uncertainty by making clear that preventive PCI is a better strategy than restricting a further intervention to those patients with refractory angina and a subsequent myocardial infarction. However, their findings do not address the question of immediate versus delayed (staged) preventive PCI, which would need to be clarified.

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