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Complete revascularization may improve outcomes in STEMI with cardiogenic shock
Patients with STEMI complicated by cardiogenic shock who underwent multivessel PCI for complete revascularization, as compared with culprit vessel-only PCI, had a lower risk for death and repeat revascularization of the infarct-related artery, according to new data.
For their study, the researchers analyzed data from the nationwide, multicenter, prospective Korean Acute Myocardial Infarction (KAMIR)-NIH registry on 659 patients with STEMI and multivessel CAD who presented with cardiogenic shock and underwent multivessel PCI (n = 260) or culprit vessel-only PCI (n = 399).
The primary outcome was all-cause death at 1 year. Secondary outcomes were a patient-oriented composite outcome — all-cause death, any MI and any repeat revascularization — and its individual components.
Results linked multivessel PCI vs. culprit vessel-only PCI to a lower risk for death (21.3% vs. 31.7%; HR = 0.59; 95% CI, 0.43-0.82). The risk for the patient-oriented composite outcome was also lower among patients who underwent multivessel PCI (28.4% vs. 42.6%; HR = 0.58; 95% CI, 0.44-0.77), which was primarily driven by the lower risk for all-cause death and a lower risk for repeat revascularization of the nonculprit vessels (6.7% vs. 8.2%; HR = 0.39; 95% CI, 0.17-0.9).
Sensitivity analyses using multivariable Cox regression, propensity-score matching and inverse probability weighting yielded similar results.
The overall incidence of new renal replacement therapy did not differ significantly between the multivessel PCI and the culprit vessel-only PCI groups at 30 days or 1 year.
In multivariable Cox proportional hazard models, at 1 year, only multivessel PCI was independently associated with a reduced risk for all-cause death (HR = 0.524; 95% CI, 0.375-0.732) and the patient-oriented composite outcome (HR = 0.578; 95% CI, 0.404-0.828).
Second-generation drug-eluting stents were used in more than 80% of both culprit and nonculprit vessels, and more than one-quarter of patients required a hemodynamic support device. Additionally, 60.4% of the multivessel PCI group underwent immediate complete revascularization and 39.6% underwent staged multivessel PCI, according to the data.
In an accompanying editorial, Jose P.S. Henriques, MD, PhD, and Bimmer E. Claessen, MD, PhD, both from department of cardiology at the Academic Medical Center, University of Amsterdam, highlighted the differences in findings between this observational study and the recent CULPRIT-SHOCK trial, which linked routine multivessel PCI in patients with cardiogenic shock to increased mortality and need for renal replacement therapy.
For instance, CULPRIT-SHOCK included only patients who underwent immediate multivessel PCI. The trial also mandated attempted revascularization in patients with chronic total occlusions — information that is unavailable in this study, they noted.
“It is evident that we need to improve the management of patients with cardiogenic shock, and for that, we will have to look beyond routine multivessel PCI,” Henriques and Claessen wrote. “The fundamental problem in cardiogenic shock is the inability of the heart to pump adequate amounts of blood to vital organs. It is most likely that the next game-changer in the treatment of cardiogenic shock is going to be timely initiation of powerful mechanical circulatory support. Until then: Keep it simple in cardiogenic shock and treat the culprit lesion only.” – by Melissa Foster
Disclosure: The authors, Henriques and Claessen report no relevant financial disclosures.