Preventive Angioplasty in Myocardial Infarction Trial

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Presentation transcript:

Preventive Angioplasty in Myocardial Infarction Trial David S Wald, Joan K Morris, Nicholas J Wald, Alexander J Chase, Richard J Edwards, Liam O Hughes, Colin Berry, Keith G Oldroyd N Engl J Med 2013;369:1115-23

Trial flow diagram Acute STEMI Exclusions Previous CABG Cardiogenic Shock Left main stem >50% Chronic total occlusion Successful Infarct-artery PCI Multivessel Disease (>50% stenosis in noninfarct-artery suitable for PCI) Randomise 600 (target) 300 300 Preventive PCI No Preventive PCI Follow-up at 6 weeks and then annually 2

One or more of the following: Primary trial outcome One or more of the following: Cardiac death Nonfatal myocardial infarction Refractory angina with evidence of ischaemia 3

Cardiac Death, Nonfatal MI or Refractory Angina in patients having infarct-artery PCI Wald DS et al. NEJM 2013:369:1115-23 Hazard Ratio 0.35 (95% CI 0.21 to 0.58), p<0.001 Risk Reduction 65% 65% preventive effect n=234 n=231

Cardiac Death, Nonfatal MI or Refractory Angina in patients having infarct-artery PCI Wald DS et al. NEJM 2013:369:1115-23 Hazard Ratio 0.36 (95% CI 0.18 to 0.73), p=0.004 Risk Reduction 64% n=234 n=231

Early Benefit Preventive PCI No Preventive PCI 0.50 0.60 0.70 0.80 0.90 1.00 Proportion without any primary outcome 6 12 18 24 30 36 Months since randomisation No Preventive PCI Preventive PCI Hazard Ratio 0.35 (95% CI 0.21 to 0.58) Wald DS et al. NEJM 2013:369:1115-23 6

Repeat Revascularisation Hazard Ratio 0.30 (95% CI 0.17 to 052), p<0.001 Risk Reduction 70% n=234 n=231

Baseline factors Preventive PCI No Preventive PCI Mean age (yrs) 62 Preventive PCI No Preventive PCI Mean age (yrs) 62 Smoker (%) 50 45 Diabetes (%) 15 21 Prior MI or stroke (%) 12 10 3 Vessel Disease (%) 39 33 Wald DS et al. NEJM 2013:369:1115-23

Procedure-related factors Preventive PCI No Preventive PCI Drug-eluting stent (%) 63 58 IIb IIIa / Bivalirudin (%) 79 78 Radial artery access (%) 80 84 Wald DS et al. NEJM 2013:369:1115-23

Post randomisation medical therapy Preventive PCI No Preventive PCI Aspirin + clopidogrel, prasugrel or ticagrelor 100% Statin 95% 97% Beta-blocker 88% 92% ACE Inhibitor or ARB 93% 91% Wald DS et al. NEJM 2013:369:1115-23

Procedure time and radiation exposure Preventive PCI No Preventive Increase Procedure time (minutes) 63 45 40% Radiation (Gycm2) 90 71 27% Wald DS et al. NEJM 2013:369:1115-23