Jackson Matthew W P, Austin David, Swanson Neil, Williams Paul D, Muir Douglas F, Hall Jim A, Wright Robert A, Sutton Andrew G C, Carter Justin, de Belder Mark A
Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK.
Coron Artery Dis. 2018 Nov;29(7):564-572. doi: 10.1097/MCA.0000000000000646.
The PRAMI and CvLPRIT trials support preventive percutaneous coronary intervention (PCI) for multivessel coronary disease found during ST-segment elevation myocardial infarction (STEMI). We assess our real-world experience of the management of multivessel disease identified during primary PCI (PPCI) in a large UK regional centre.
All STEMI patients who underwent culprit-only PPCI during the study period (August 2011 to August 2013) were retrospectively assessed for eligibility to each trial. The two resulting groups were designated as the 'observational' cohorts. Primary outcomes were then determined and compared with the culprit-only revascularisation cohorts from the respective published randomized controlled trials (RCTs).
A total of 1143 consecutive cases were presented during the study period. Of these, 343 would have been suitable for inclusion to PRAMI and were included in the 'observational PRAMI' cohort; 196 patients were included in the 'observational CvLPRIT' cohort.The 'observational PRAMI' cohort experienced fewer primary outcome events (13.1 vs. 22.9%), cardiac deaths (0.6 vs. 4.3%) and nonfatal myocardial infarctions (3.5 vs. 8.7%) than the culprit-only PCI PRAMI cohort (n=231); there were significantly more diabetics (P=0.022) and anterior STEMI initial presentations in the culprit-only PCI PRAMI cohort. Primary outcomes were comparable to those of the preventive PCI PRAMI cohort.The 'observational CvLPRIT' cohort showed no significant difference in primary outcomes over 12 months (16.8 vs. 21.2%), but significantly lower all-cause mortality (2 vs. 6.9%) than the culprit-only PCI CvPLRIT cohort (n=146). The 30-day event rates were similar to the preventive PCI arm; the 12-month events were better than the nonpreventive, but not as good as the preventive RCT cohorts.
Outcomes from culprit-only primary PCI for multivessel disease in patients selected by the RCT criteria from an all-comers population representing real-life experience are better than those published in the two main RCTs. The RCTs may have selected a high-risk population for study exaggerating the benefits of preventive PCI.
PRAMI和CvLPRIT试验支持对ST段抬高型心肌梗死（STEMI）期间发现的多支冠状动脉疾病进行预防性经皮冠状动脉介入治疗（PCI）。我们评估了在英国一个大型地区中心进行的直接PCI（PPCI）期间发现的多支血管疾病管理的实际经验。
对研究期间（2011年8月至2013年8月）所有仅对罪犯血管进行PPCI的STEMI患者进行回顾性评估，以确定其是否符合每项试验的入选标准。由此产生的两组被指定为“观察性”队列。然后确定主要结局，并与各自发表的随机对照试验（RCT）中仅对罪犯血管进行血运重建的队列进行比较。
研究期间共出现1143例连续病例。其中，343例适合纳入PRAMI，被纳入“观察性PRAMI”队列；196例患者被纳入“观察性CvLPRIT”队列。“观察性PRAMI”队列的主要结局事件（13.1%对22.9%）、心源性死亡（0.6%对4.3%）和非致命性心肌梗死（3.5%对8.7%）少于仅对罪犯血管进行PCI的PRAMI队列（n = 231）；仅对罪犯血管进行PCI的PRAMI队列中的糖尿病患者（P = 0.022）和前壁STEMI初始表现明显更多。主要结局与预防性PCI的PRAMI队列相当。“观察性CvLPRIT”队列在12个月内的主要结局无显著差异（16.8%对21.2%），但全因死亡率（2%对6.9%）明显低于仅对罪犯血管进行PCI的CvPLRIT队列（n = 146）。30天事件发生率与预防性PCI组相似；12个月事件发生率优于非预防性组，但不如预防性RCT队列。
在代表现实生活经验的所有患者人群中，根据RCT标准选择的患者仅对罪犯血管进行原发性PCI治疗多支血管疾病的结局优于两项主要RCT中公布的结局。RCT可能选择了一个高危人群进行研究，夸大了预防性PCI的益处。
