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Outcomes of Culprit Lesion PCI in Cardiogenic Shock After Cardiac Arrest
Quick Takes
- Cardiac arrest is observed in >50% of patients admitted with infarct-related cardiogenic shock.
- Patients with cardiac arrest were younger and had less high-risk characteristics, but a higher rate of signs of impaired end-organ perfusion on admission.
- Culprit lesion-only PCI as opposed to immediate multivessel PCI is the preferred strategy in patients with cardiogenic shock both with and without cardiac arrest.
Study Questions:
What are the characteristics and outcomes of culprit lesion percutaneous coronary intervention (PCI) of patients with infarct-related cardiogenic shock (CS) stratified by cardiac arrest (CA) in the CULPRIT-SHOCK randomized trial and registry?
Methods:
The investigators analyzed patients with CS with and without CA from the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) study. The primary endpoint of the present analysis was a composite of death from any cause or severe renal failure leading to renal replacement therapy within 30 days after randomization for the comparison of culprit lesion versus multivessel PCI similar to the randomized trial. Secondary endpoints included 30-day and 1-year mortality, length of intensive care unit (ICU) stay, length of hospital stay, duration of catecholamine therapy, and duration of mechanical ventilation, recurrent myocardial infarction, and additional revascularization procedures. Cox proportional hazard regression models were used to estimate the unadjusted and adjusted effect of CA on the primary endpoint, death within 30 days, death, or renal replacement therapy within 365 days after randomization and death within 365 days.
Results:
Among 1,015 patients, 550 (54.2 %) had CA. Patients with CA were younger, more frequently male, had lower rates of peripheral artery disease, glomerular filtration rate <30 mL/min and left main disease, and presented more often with clinical signs of impaired organ perfusion. The composite of all-cause death or severe renal failure within 30 days occurred in 51.2% in CA patients versus 48.5% in non-CA patients (p = 0.39) and 1-year death in 53.8% versus 50.4% (p = 0.29). In a multivariate analysis, CA was an independent predictor of 1-year mortality (hazard ratio, 1.27; 95% confidence interval, 1.01-1.59). In the randomized trial, culprit lesion-only PCI was superior to immediate multivessel PCI both in patients with and without CA (p for interaction = 0.6).
Conclusions:
The authors report that culprit lesion-only PCI is the preferred strategy both in patients with and without CA.
Perspective:
This predefined secondary analysis of the CULPRIT-SHOCK trial reports that CA is observed in >50% of patients admitted with infarct-related CS and that patients with CA were younger and had less high-risk characteristics, but a higher rate of signs of impaired end-organ perfusion on admission. Furthermore, culprit lesion-only PCI as opposed to immediate multivessel PCI was beneficial both in patients with and without CA. These findings further support a Class III/Harm recommendation for PCI of a noninfarct artery at the time of primary PCI in patients with CS in the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine
Keywords: Acute Coronary Syndrome, Catecholamines, Coronary Artery Disease, Heart Arrest, Glomerular Filtration Rate, Intensive Care Units, Length of Stay, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Perfusion, Peripheral Arterial Disease, Renal Insufficiency, Respiration, Artificial, Secondary Prevention, Shock, Cardiogenic
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