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Multivessel PCI in STEMI With Cardiogenic Shock
Study Questions:
What is the clinical utility of multivessel percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock?
Methods:
The author performed a comparative effectiveness analysis of multivessel versus infarct-related artery (IRA)-only PCI among patients undergoing primary PCI for cardiogenic shock and enrolled in the Korea Acute Myocardial Infarction-National Institutes of Health (KAMIR-NIH) Registry. The primary outcome was 1-year all-cause death, and secondary outcomes included POCO (patient-oriented composite outcome, a composite of all-cause death, any myocardial infarction, and any repeat revascularization) and its individual components.
Results:
Out of 659 patients, 260 were treated by multivessel PCI, and 399 underwent IRA-only PCI. The risk of all-cause death (21.3% vs. 31.7%; hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.43-0.82; p = 0.001) and non-IRA repeat revascularization (6.7% vs. 8.2%; HR, 0.39; 95% CI, 0.17-0.90; p = 0.028) was significantly lower in the multivessel PCI group than in the IRA-only PCI group. Results were consistent after multivariable regression, propensity-score matching, and inverse probability weighting to adjust for baseline differences.
Conclusions:
In this observational study, compared with IRA-only PCI, multivessel PCI was associated with a better outcome in patients with shock complicating STEMI.
Perspective:
The data on IRA-only versus complete revascularization in patients with shock complicating STEMI are mixed. Observational studies cannot totally eliminate residual confounding, and a similar sized randomized trial to test this question (CULPRIT-SHOCK trial; N Engl J Med 2017;377:2419-32) demonstrated better outcomes with an IRA-only approach. Based on the randomized data, an IRA-only approach should be the preferred strategy when dealing with patients with STEMI who are in cardiogenic shock, and multivessel PCI should be reserved for unique clinical circumstances.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS
Keywords: Acute Coronary Syndrome, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Shock, Cardiogenic, Treatment Outcome, Vascular Diseases
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