title: Randomized trial of preventive angioplasty in myocardial infarction.
abstract: BACKGROUND
  In acute ST-segment elevation myocardial infarction (STEMI), the use of percutaneous coronary intervention (PCI) to treat the artery responsible for the infarct (infarct, or culprit, artery) improves prognosis. The value of PCI in noninfarct coronary arteries with major stenoses (preventive PCI) is unknown.
  
  
  METHODS
  From 2008 through 2013, at five centers in the United Kingdom, we enrolled 465 patients with acute STEMI (including 3 patients with left bundle-branch block) who were undergoing infarct-artery PCI and randomly assigned them to either preventive PCI (234 patients) or no preventive PCI (231 patients). Subsequent PCI for angina was recommended only for refractory angina with objective evidence of ischemia. The primary outcome was a composite of death from cardiac causes, nonfatal myocardial infarction, or refractory angina. An intention-to-treat analysis was used.
  
  
  RESULTS
  By January 2013, the results were considered conclusive by the data and safety monitoring committee, which recommended that the trial be stopped early. During a mean follow-up of 23 months, the primary outcome occurred in 21 patients assigned to preventive PCI and in 53 patients assigned to no preventive PCI (infarct-artery-only PCI), which translated into rates of 9 events per 100 patients and 23 per 100, respectively (hazard ratio in the preventive-PCI group, 0.35; 95% confidence interval [CI], 0.21 to 0.58; P<0.001). Hazard ratios for the three 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.
  
  
  CONCLUSIONS
  In patients with STEMI and multivessel coronary artery disease undergoing infarct-artery PCI, preventive PCI in noninfarct coronary arteries with major stenoses significantly reduced the risk of adverse cardiovascular events, as compared with PCI limited to the infarct artery. (Funded by Barts and the London Charity; PRAMI Current Controlled Trials number, ISRCTN73028481.).
authors.affiliation: Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom. d.s.wald@qmul.ac.uk
authors.forename: David S
authors.initials: DS
authors.lastname: Wald
authors.forename: Joan K
authors.initials: JK
authors.lastname: Morris
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Wald
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Chase
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Edwards
authors.forename: Liam O
authors.initials: LO
authors.lastname: Hughes
authors.forename: Colin
authors.initials: C
authors.lastname: Berry
authors.forename: Keith G
authors.initials: KG
authors.lastname: Oldroyd
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000628:therapy; D015906:Angioplasty, Balloon, Coronary; D023921:Coronary Stenosis / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000401:mortality; D006801:Humans; D057194:Intention to Treat Analysis; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy*; D012306:Risk; D055502:Secondary Prevention; D016896:Treatment Outcome