Multivessel PCI for STEMI With Cardiogenic Shock

Study Questions:

What are the outcomes following culprit vessel or multivessel revascularization in patients with ST-segment elevation myocardial infarction (STEMI), cardiogenic shock, and multivessel disease (MVD)?

Methods:

From 16,620 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) in a nationwide, prospective, multicenter registry between January 2006 and December 2012, 510 eligible patients were selected and divided into culprit vessel revascularization (n = 386, 75.7%) and multivessel revascularization (n = 124, 24.3%) groups. The primary outcomes were in-hospital mortality and all-cause death during a median 194-day follow-up. A weighted Cox regression model was constructed to determine the hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes in the two groups.

Results:

Compared with culprit vessel revascularization, multivessel revascularization had a significantly lower adjusted risk of in-hospital mortality (9.3% vs. 2.4%; HR, 0.263; 95% CI, 0.149-0.462; p < 0.001) and all-cause death (13.1% vs. 4.8%; HR, 0.400; 95% CI, 0.264-0.606; p < 0.001), mainly because of fewer cardiac deaths (9.7% vs. 4.8%; HR, 0.510; 95% CI, 0.329-0.790; p = 0.002). In addition, multivessel revascularization significantly decreased the adjusted risk of the composite endpoint of all-cause death, recurrent MI, and any revascularization (20.3% vs. 18.1%; HR, 0.728; 95% CI, 0.55-0.965; p = 0.026).

Conclusions:

The authors concluded that compared with culprit vessel revascularization, multivessel revascularization at the time of primary PCI was associated with better outcomes in patients with STEMI with cardiogenic shock.

Perspective:

This study reports that adjusted in-hospital mortality and all-cause death during follow-up were significantly lower following multivessel versus culprit vessel revascularization during primary PCI in patients with STEMI with cardiogenic shock and MVD. Additionally, multivessel revascularization was associated with a lower adjusted risk of the composite of all-cause death, recurrent MI, and any revascularization. These results support the current guidelines regarding revascularization in STEMI patients with cardiogenic shock. Whether multivessel PCI may be beneficial in patients with STEMI without shock is being investigated in ongoing studies.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Hospital Mortality, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Shock, Cardiogenic


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