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Preventive Angioplasty in myocardial infarction trial

Centre of Environmental and Preventive Medicine

Funding Body: Barts and The London Charity
Project Investigator: David Wald

Overview

Overview

The Preventive Angioplasty in Myocardial Infarction (PRAMI) Trial is a randomised trial comparing two strategies for treating patients with an acute heart attack:
•    therapeutic angioplasty (treatment to unblock only the artery causing the heart attack);
•    therapeutic plus preventive angioplasty (additional angioplasty to treat other arteries that are found to be narrowed but were not the cause of the heart attack).

Background

Patients who suffer a heart attack are best treated by angioplasty, a procedure in which narrow tubes are fed up to the heart from arteries in the leg or arm under x-ray guidance. Steerable guide-wires are used to position expandable stents (cylindrical metal scaffolds) to restore blood flow to the blocked artery causing the heart attack (the culprit artery) - a so-called "therapeutic angioplasty".
During the angioplasty procedure narrowed coronary arteries are often identified that were not the cause of the heart attack. Once the culprit artery has been unblocked, the practice of dilating these other arteries varies from doctor to doctor. Some believe these non-culprit arteries may cause future heart attacks which could be avoided by performing a "preventive angioplasty" as part of the initial procedure. Treating non-culprit arteries, however, carries additional risks to the patient (such as bleeding, stroke and death which may increase by 0.5-1%) and costs more, leading other doctors to take the view that drugs (such as aspirin and cholesterol lowering drugs) are sufficient therapy and that the risk and cost of an extended procedure outweighs the benefits.
Until the results of this trial were known it was uncertain whether routine preventive angioplasty in "non-culprit" arteries reduced the risk of a future cardiac event, to an extent that would justify the higher cost and greater risk that is associated with the extended procedure. This trial has helped to answer this question.
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