Culprit vessel-only PCI linked to lower mortality in MI with cardiogenic shock

SAN DIEGO — In patients with acute MI complicated by cardiogenic shock, culprit vessel-only revascularization, compared with multivessel revascularization, was associated with lower mortality, according to registry data presented at the Society for Cardiovascular Angiography and Interventions Scientific Sessions.

In this study, Andrew McNeice, MD, from the Victoria Heart Institute in Canada, and colleagues compared outcomes of culprit vessel-only PCI vs. multivessel PCI in 649 patients who had an acute MI and cardiogenic shock with multivessel disease enrolled in the British Columbia Cardiac Registry between 2008 and 2014. Endpoints included all-cause mortality at 30 days and 1 year.

At 30 days, the mortality rate was 23.7% in patients who underwent culprit vessel-only PCI vs. 34.5% in patients who underwent immediate multivessel PCI (P = .004). Similarly, at 1 year, the mortality rate was 32.6% in the culprit vessel-only PCI arm vs. 44.3% in the multivessel PCI arm (P = .003).

Additionally, culprit vessel-only PCI was shown to be an independent predictor for survival at 30 days (HR = 0.78; 95% CI, 0.64-0.97) and 1 year (HR = 0.78; 95% CI, 0.64-0.97), findings that were also confirmed in propensity-matched cohorts, McNeice said during a press conference.

In a subgroup analysis of anatomical subsets of non-culprit disease, only PCI of left anterior descending disease was associated with increased mortality at 1 year (HR = 1.51; 95% CI, 1.13-2.01), particularly with PCI of non-culprit proximal LAD disease (HR = 1.82; 95% CI, 1.2-2.76).

Culprit vessel-only PCI also appeared to be a preferable revascularization strategy particularly in patients aged younger than 80 years, patients without diabetes and patients presenting with STEMI.

“In the setting of cardiogenic shock, non-culprit PCI may result in an exaggerated acute myocardial injury in the non-infarcted myocardium; thus, the greater the subtended myocardial territory, the greater the risk associated with non-culprit PCI, which probably goes against what we currently thought,” McNeice said.

The results raised the question of whether there are deleterious effects of immediate multivessel intervention, he noted. When comparing these results with data from the CULPRIT-SHOCK trial, McNeice said the Kaplan-Meier curves were similar and that the deleterious effect of immediate multivessel PCI separated early, particularly within the first 10 days.

“We’re posing that in the setting of cardiogenic shock, the negative impact associated with immediate multivessel intervention is acute and transient and is probably the result of the period of the shock physiology itself,” he said.

Although the mortality rate appears to be lower with culprit vessel-only intervention, a multivessel intervention may be considered in selected patients in the setting of non-culprit left circumflex and right CAD, McNeice said. – by Melissa Foster

Reference:

McNeice A. Late Breaking Clinical Science I. Presented at: Society for Cardiovascular Angiography and Interventions Scientific Sessions; April 25-28, 2018; San Diego.

Disclosure: McNeice reports no relevant financial disclosures.