A 62-year-old man with NSTEMI (peak troponin I 8.2 ng/mL) undergoes coronary angiography showing 95% stenosis of the proximal LAD. He is currently on aspirin, ticagrelor, unfractionated heparin, and atorvastatin. Which additional therapy has been shown in the PRAMI trial to reduce recurrent MI in this setting?
- A Staged PCI of non-culprit lesions within 6 weeks guided by FFR
- B Abciximab (GP IIb/IIIa inhibitor) for 12 hours post-PCI
- C Prasugrel instead of ticagrelor for higher platelet inhibition
- D Preventive PCI of non-culprit lesions with ≥ 50% stenosis at the time of primary PCI ✓
Explanation
The PRAMI trial (2013) randomised patients with STEMI (not NSTEMI, but the principle is tested) and multivessel disease to preventive PCI of non-infarct-related stenoses ≥ 50% versus PCI of the infarct-related artery only. The preventive PCI group showed a significant reduction in the composite of death from cardiac causes, nonfatal MI, and refractory angina (HR 0.35). Subsequently, the COMPLETE trial confirmed this for all non-culprit lesions in STEMI. In NSTEMI with multivessel disease, complete revascularisation guided by angiographic or physiological assessment is now preferred per current guidelines. FFR-guided staged PCI is also evidence-based but the PRAMI principle of immediate/early preventive PCI is the key trial finding tested.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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