Based on this report from the PRAMI trial, we can no longer assume that secondary lesions in acute myocardial infarction are innocent until proven guilty.
It has been a core belief in interventional cardiology that percutaneous coronary intervention in noninfarct lesions does not prevent death and MI. Cardiologists have refrained from treating anything but the infarct lesion acutely, and they usually withhold further treatment unless a patient is symptomatic.
But patients with acute ST-segment elevation MI have a substantial risk for early, recurrent events, in contrast to patients with stable angina. Why? Coronary artery disease is accompanied by systemic abnormalities in coagulation, inflammation, and endothelial function, with multiple inflamed lesions. Patients with acute coronary syndrome have prominent, systemic derangements in these processes. The aggressive, acute treatment used in PRAMI may have stabilized these not-so-innocent lesions.
The PRAMI findings suggest that there are no healthy coronary arteries in a patient with acute STEMI. Does this mean that these patients need extensive revascularization? It is plausible that the risk from noninfarct lesions is independent of their hemodynamic severity.
The strategy employed in this study differs markedly from current practice. Guidelines have cautioned against treating multiple vessels during acute STEMI, particularly when the secondary sites are not clearly causing ongoing hemodynamic instability. The PRAMI results suggest that widening the scope of interventional therapy in acute STEMI patients is a promising new approach to management.
Dr. Laura Mauri is an interventional cardiologist at Brigham and Women’s Hospital, professor of medicine at Harvard University, and chief scientific officer of the Harvard Clinical Research Institute in Boston. She has been a consultant to Biotronik, has been on an advisory board of St. Jude, and she has received research grants from seven other drug or device-manufacturing companies. She made these comments in an editorial that accompanied the published version of the PRAMI report (N. Engl. J. Med. 2013 [doi:10.1056/NEJMe1309383]).
