The PRAMI Trial was a randomized controlled trial that studied 465 patients with acute ST elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) of the infarct artery. Patients were randomized to either preventive PCI of significant stenoses in non-infarct arteries immediately during the initial procedure or to undergo PCI of non-infarct arteries only if refractory angina and objective evidence of ischemia developed. The primary outcome of death from cardiac causes, nonfatal myocardial infarction, or refractory angina occurred in 9% of patients who received preventive PCI versus 23% of patients who did not, demonstrating that preventive PCI of non-infarct arteries reduced adverse cardiovascular events.

1. The PRAMI Trial
Randomized Trial of Preventive Angioplasty in
Myocardial Infarction (PRAMI Trial)
N Engl J Med 2013; 369:1115-1123

2. The idea is to present an important recent trial in relation to a
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Clinical vignette including relevant images
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Brief description of the trial
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Single slide highlighting the most important findings of the trial
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Relevant clinical guidelines and relationship of the trial to the guideline
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Viewer comment opportunity

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. ECG on Presentation

5. Coronary Angiography

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. Results: The PRAMI Trial
(slide will need copyright approval or modification)

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. 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.