Multivessel PCI may be associated with lower in-hospital mortality but higher peri-procedural complications among patients with NSTEMI, multivessel disease and cardiogenic shock, according to a study published April 28 in JACC: Cardiovascular Interventions.

Using data from ACC’s CathPCI Registry, Mohamed A. Omer, MD, MS, FACC, et al., compared in-hospital and long-term outcomes among patients with NSTEMI, multivessel disease and cardiogenic shock who underwent multivessel vs. culprit vessel-only PCI between 2009 and 2018. The study cohort consisted of 25,324 patients with NSTEMI and cardiogenic shock. Among all patients, the average age was 69.2 years, 67% were men, 84.1% had hypertension, 74.4% had dyslipidemia and 52.4% had diabetes. A total of 9,791 patients (38.7%) underwent multivessel PCI. Patients undergoing multivessel PCI were less likely to have had CABG previously but more likely to have had heart failure within two weeks of presentation, cardiomyopathy and lower ejection fraction.

Results showed that unadjusted rates of all-cause mortality were similar among patients undergoing multivessel PCI (32.7%) vs. culprit vessel-only PCI (31.8%). However, those undergoing multivessel PCI vs. culprit vessel-only PCI had higher rates of bleeding (14.6% vs. 9.6%); stroke (2.1% vs. 1.6%); new dialysis requirement (6.3% vs. 4.4%) and cardiac tamponade (0.4% vs. 0.2%). After propensity matching 7,864 patients in each group with similar demographics and clinical characteristics, in-hospital morality was significantly lower in patients who received multivessel PCI (30.9%) vs. culprit vessel-only PCI (34.4%). Among the matched cohort, multivessel PCI was associated with a higher risk of bleeding and new dialysis requirement, but there was no association with a higher risk of periprocedural stroke or cardiac tamponade.

Medicare data was available for 7,618 patients. Of these, 2,708 (35.6%) received multivessel PCI, while 4,910 (64.5%) received culprit-vessel only PCI. Propensity matching in this cohort showed similar rates of long-term mortality among both groups.

According to the researchers, multivessel PCI was associated with lower in-hospital mortality but higher peri-procedural bleeding and new dialysis requirement, compared with culprit vessel-only PCI. Differences in in-hospital outcomes were not associated with differences in long-term mortality, “suggesting that the acute impact on outcomes should be most influential in clinical decision-making,” they write. They conclude that the findings “highlight the complexity of individualized decision-making for patients with NSTEMI and [multivessel disease] complicated by cardiogenic shock until more definitive prospective trials are conducted.”

“Given the lack of data specifically for patients with NSTEMI, this is an important contribution to the literature,” M. Bilal Iqbal, MD, PhD, writes in an editorial comment. He adds that the study underscores the need for future research on the optimal revascularization strategy for patients with NSTEMI and cardiogenic shock. “Until such data is available, we will need to be guided by the available evidence and our clinical acumen to make decisions in this complex and sick patient population,” he concludes.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Prevention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Hypertension

Keywords: Shock, Cardiogenic, Hospital Mortality, Myocardial Infarction, Percutaneous Coronary Intervention, Cardiac Tamponade, Prospective Studies, Stroke Volume, Medicare, Renal Dialysis, Heart Failure, Registries, Diabetes Mellitus, Cardiomyopathies, Hypertension, Stroke, Dyslipidemias, Decision Making, Coronary Artery Bypass, National Cardiovascular Data Registries, CathPCI Registry

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