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Multi- vs. Culprit-Vessel PCI in Cardiogenic Shock
Quick Takes
- Patients with multivessel CAD who receive MCS for AMI and shock have a 65-70% in-hospital survival rate.
- Multivessel PCI did not affect in-hospital survival compared to culprit-only PCI.
- Longer follow-up will be needed to quantify benefit of nonculprit PCI for AMI shock patients treated with mechanical support.
Study Questions:
What are outcomes among patients undergoing multivessel percutaneous coronary intervention (MV-PCI) compared to culprit-vessel only PCI (CV-PCI) in the setting of acute myocardial infarction (AMI) with cardiogenic shock (CS) and receiving mechanical circulatory support (MCS)?
Methods:
This is a retrospective analysis from the National Cardiogenic Shock Initiative (NCSI) of patients presenting with AMI with CS and receiving MCS. Patients with multivessel coronary artery disease (MV-CAD) from July 2016 to December 2019 were stratified based on revascularization strategy. CV-PCI was compared to MV-PCI. The primary outcome was hospital survival. Secondary outcomes included rates of acute kidney injury (defined as an increase in creatinine of 1.5 times from baseline, excluding patients with end-stage renal disease) and length of stay.
Results:
Of 198 patients with MV-CAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, gender, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of MI. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 hours. However, 24 hours from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury (AKI) were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI, p = 0.51; and 29.9% vs. 34.2%, p = 0.64, respectively).
Conclusions:
In patients with MV-CAD presenting with AMI with CS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and AKI when compared to culprit-only PCI.
Perspective:
This is a retrospective analysis from the NCSI. Of the 300 patients enrolled across 57 hospitals with AMI and shock, 66% had MV-CAD. Treatment approach of MV-CAD was not adjudicated, which limits the conclusions. All patients received Impella insertion, with the majority receiving it prior to PCI, as per the NCSI protocol. There did not appear to be a benefit to MV-PCI in this cohort of patients. The authors concluded that it is safe to proceed with MV-PCI among AMI patients with CS; however, their data do not show clinical efficacy of such an approach for short-term outcomes. It may be that longer-term follow-up would shed light on clinical benefit of more complete revascularization with lower rates of heart failure and readmission. For now, risks of additional PCI (time, resources, contrast, complications) need to be weighed against benefits of more complete revascularization in each individual patient presenting with AMI plus shock and receiving mechanical support.
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, Acute Kidney Injury, Coronary Artery Disease, Creatinine, Diabetes Mellitus, Heart Failure, Length of Stay, Myocardial Infarction, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Shock, Cardiogenic
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