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