Multivessel PCI confers poor outcomes in acute MI, cardiogenic shock
Among patients with acute MI, cardiogenic shock and multivessel CAD, multivessel PCI was associated with elevated risk for in-hospital complications and mortality compared with culprit-lesion-only PCI, researchers reported.
In addition, hospitals with high rates of performing multivessel PCI on patients with STEMI, cardiogenic shock and multivessel CAD had higher rates of in-hospital mortality for this population compared with hospitals that performed multivessel PCI on these patients less often, according to the researchers.
‘Urgent need to change practice’
“With recent evidence suggesting harm with this strategy, there appears to be an urgent need to change practice and improve outcomes in this high-risk population,” Rohan Khera, MD, MS, assistant professor in the section of cardiovascular medicine at Yale School of Medicine and cardiologist at Yale New Haven Hospital, and colleagues wrote.
The researchers analyzed 64,301 patients with multivessel CAD from the CathPCI registry (mean age, 66 years; 32% women) who underwent PCI for acute MI and cardiogenic shock from July 2009 to May 2018.
Among the overall cohort, 34.9% underwent multivessel PCI, and among those with STEMI, 31.5% had multivessel PCI. Use of multivessel PCI rose 6.7% per year for those with acute MI and 5.8% per year for those with STEMI.
After adjustment for a variety of factors, multivessel PCI was associated with increased odds of in-hospital complications in the acute MI population (adjusted OR = 1.18; 95% CI, 1.14-1.23) and in the STEMI population (aOR = 1.19; 95% CI, 1.17-1.26) compared with culprit-vessel-only PCI, according to the researchers. This remained true after exclusion of patients with STEMI and left main artery disease.
Multivessel PCI conferred higher odds of in-hospital mortality among patients with STEMI (aOR = 1.11; 95% CI, 1.06-1.16), but lower odds among all patients with acute MI (aOR = 0.96; 95% CI, 0.92-0.99) and no difference among patients with STEMI whose culprit vessel was not the left main artery (aOR = 0.97; 95% CI, 0.92-1.01), the researchers wrote.
There was no difference between the groups in 1-year mortality rates (aOR = 0.97; 95% CI, 0.9-1.04).
Choice of multivessel PCI for this population, even for patients with similar characteristics, varied widely across hospitals (median OR = 1.37; 95% CI, 1.33-1.41), Khera and colleagues wrote.
Hospitals in the highest quartile of performing multivessel PCI for patients with STEMI, cardiogenic shock and multivessel disease had higher rates of in-hospital mortality for that population than hospitals in the lowest quartile (aOR = 1.1; 95% CI, 1.02-1.19), according to the researchers.
Unintended harms
In a related editorial, Colette DeJong, MD, resident physician at the School of Medicine at University of California, San Francisco, and Cardiology Today Editorial Board Member Rita F. Redberg, MD, professor of medicine at the School of Medicine at University of California, San Francisco, wrote that the study results confirm the findings of the CULPRIT-SHOCK randomized trial.
“This is a time to be reminded that interventions that are conceptually sound and delivered with the best of intentions do not always stand up to empirical testing and may carry unintended harms,” they wrote. “We must be guided by randomized clinical trials, especially when buttressed by consistent observational data. Despite our good intentions, it is clear that primary nonculprit PCI for patients with acute MI in cardiogenic shock does not benefit and can harm, and the practice should be abandoned for patient safety.”
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