Kongres ESC Amsterdam 2013 – prezentacja wyników badania PRAMI

Wrzesień 17, 2013  |  Udostępnij  | 
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W ostatnich dniach (31 sierpnia – 4 września) w Amsterdamie odbyła się coroczna konferencja Europejskiego Towarzystwa Kardiologicznego (ESC). To największe w Europie spotkanie kardiologów jak zwykle obfitowało w prezentacje najnowszych osiągnięć w dziedzinie chorób układu krążenia. Wyniki najciekawszych badań będziemy prezentować w kolejnych artykułach na stronie. Oto pierwszy z nich, zapraszamy do lektury! W trakcie konferencji i jednocześnie na stronach New England Journal of Medicine zaprezentowano wyniki projektu naukowego określonego akronimem PRAMI[1]. Jego celem było zbadanie, czy w trakcie procedury angioplastyki wieńcowej (PCI) u pacjentów z zawałem serca z uniesieniem odcinka ST (STEMI) korzystniejsze jest zaopatrywanie jedynie naczynia odpowiedzialnego za zawał, czy może należy przy okazji tej samej procedury stentować także pozostałe zwężenia. O ile PCI tętnicy odpowiedzialnej za ostre niedokrwienie jest procedurą o niewątpliwie udowodnionej korzystności, o tyle jednoczasowe, prewencyjne poszerzanie zmian w naczyniach nieodpowiedzialnych za STEMI jest procedurą słabo przebadaną. Zespół projektu PRAMI w ciągu 5 lat, między 2008 a 2013 rokiem, włączył do badania 465 pacjentów z zawałem serca z uniesieniem odcinka ST. Losowo zostali oni podzieleni na dwie grupy: badaną – 234 chorych leczonych PCI naczynia dozawałowego z jednoczasową plastyką prewencyjną oraz kontrolną – 231 chorych, którym wszczepiono stent jedynie do tętnicy odpowiedzialnej za niedokrwienie, pozostawiając nieposzerzone zwężenie >50 % w drugim naczyniu. Na złożony, pierwszorzędowy punkt końcowy składały się: zgon z przyczyn krążeniowych, zawał serca niezakończony zgonem, oraz dławica piersiowa nieodpowiadająca na leczenie farmakologiczne. Z założenia obserwacja miała trwać 5 lat, jednak badanie zostało przerwane, gdyż korzyści jakie wynikały z prewencyjnego PCI dla chorych z grupy badanej stały się ewidentne. Ostatecznie, średni czas follow-up wyniósł 23 miesiące. W tym okresie w grupie kontrolnej u 53 pacjentów wystąpiły zdarzenia tworzące złożony punkt końcowy, w grupie badanej takich zdarzeń było 21. Ryzyko wystąpienia punktu końcowego było więc o 65% niższe wśród osób poddanych prewencyjnej PCI (p<0,001). Zaobserwowano także istotną statystycznie redukcję ryzyka względnego poszczególnych składowych złożonego punktu końcowego – o 68% mniejszą częstość zawałów niezakończonych zgonem oraz 65% mniej przypadków dusznicy niepoddającej się leczeniu farmakologicznemu. Jeśli chodzi o ryzyko zgonu z przyczyn kardiologicznych, uzyskano jedynie trend zmierzający do jego zmniejszenia (HR=0,34), jednak wynik ten nie uzyskał istotności statystycznej (p=0,07). Częstość powikłań związanych z procedurami była podobna w obu grupach, natomiast, co zrozumiałe, w grupie badanej zabiegi trwały dłużej i narażały pacjentów na wyższą dawkę promieniowania. Nie była to jednak różnica bardzo znacząca – chorzy z grupy badanej przyjmowali dodatkową ilość promieni, która odpowiada tej stosowanej w trakcie rutynowej koronarografii. Wyniki badania jednoznacznie sugerują, że przeprowadzanie prewencyjnej PCI naczynia nieodpowiadającego za niedokrwienie w trakcie zabiegu angioplastyki tętnicy dozawałowej u chorych ze STEMI poprawia wyniki leczenia. Warto podkreślić, że stoi to w sprzeczności z dotychczasowymi wytycznymi, zarówno europejskimi jak i amerykańskimi, które odradzają, jak na razie, wszczepiania stentów do naczyń niepowodujących ostrego niedokrwienia. Być może wytyczne te będą musiały zostać poddane korekcie. 1. Wald DS et al., Randomized Trial of Preventive Angioplasty in Myocardial Infarction, N Engl J Med, 1 Sep 2013



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