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Revascularization for Multivessel CAD in AMI and Shock
Quick Takes
- One-third of patients identified in the CathPCI Registry with AMI and cardiogenic shock underwent multivessel PCI during the index procedure, with increasing use of multivessel PCI between 2009 and 2018.
- There was evidence of higher mortality in patients with STEMI who were treated using a multivessel PCI strategy and in patients at hospitals that more frequently used this strategy for STEMI and shock.
- Based on available randomized and other evidence, there is little justification for multivessel PCI in cardiogenic shock and there appears to be a need to de-adopt practices that could be associated with harm.
Study Questions:
What were the patterns in the use of multivessel percutaneous coronary intervention (PCI) versus culprit-vessel PCI in acute myocardial infarction (AMI) and cardiogenic shock and outcomes in the United States from 2009 to 2018?
Methods:
The investigators conducted a cohort study and identified all patients in the CathPCI Registry with AMI and cardiogenic shock who had multivessel coronary artery disease (CAD) and underwent PCI between July 1, 2009, and March 31, 2018. The primary outcome was in-hospital mortality. Temporal trends and hospital variation in PCI strategies were evaluated, while accounting for differences in case mix using hierarchical models. As a secondary outcome, the association of PCI strategy with post-discharge outcomes was evaluated in the subset of patients who were Medicare beneficiaries.
Results:
Of 64,301 patients (mean [standard deviation] age, 66.4 [12.5] years; 20,366 [31.7%] female; 54,538 [84.8%] White) with AMI and shock at 1,649 US hospitals, 34.9% had primary multivessel PCI. In the subgroup of 48,943 patients with ST-segment elevation myocardial infarction (STEMI), 31.5% underwent multivessel PCI. Between 2009 and 2018, this percentage increased by 6.7% per year for AMI and 5.8% for STEMI. Overall, multivessel PCI was associated with a greater adjusted risk of in-hospital complications (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.14-1.23) and with greater in-hospital mortality in patients with STEMI (odds ratio [OR], 1.11; 95% CI, 1.06-1.16). Among Medicare beneficiaries, multivessel PCI use was not associated with post-discharge 1-year mortality (51.5% vs. 49.8%; risk-adjusted OR, 0.97; 95% CI, 0.90-1.04; p = 0.37). Significant hospital variation was found in the use of multivessel PCI, with a higher multivessel PCI rate for similar patients across hospitals (median OR, 1.37; 95% CI, 1.33-1.41). Patients at hospitals with high rates of PCI in STEMI use had higher risk-adjusted in-hospital mortality (highest vs. lowest hospital multivessel PCI quartile: OR, 1.10; 95% CI, 1.02-1.19).
Conclusions:
The authors concluded that multivessel PCI was increasingly used as the revascularization strategy in AMI and shock and that hospitals that used multivessel PCI more, especially among patients with STEMI, had worse outcomes.
Perspective:
This cohort study reports that one-third of patients with AMI and cardiogenic shock in the CathPCI Registry underwent multivessel PCI, with increasing use of multivessel PCI between 2009 and 2018. Furthermore, there was evidence of higher mortality in patients with STEMI who were treated using a multivessel PCI strategy and in patients at hospitals that more frequently used this strategy for STEMI and shock. The consistency of the association observed in the patient-level and hospital-level analyses, as well their congruity with results from the CULPRIT-SHOCK trial, suggest that the results are likely valid. Based on available randomized and other evidence, there is little justification for multivessel PCI in cardiogenic shock and there appears to be a need to de-adopt practices that could be associated with harm.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, CathPCI Registry, Coronary Artery Disease, Heart Failure, Hospital Mortality, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Secondary Prevention, Shock, Shock, Cardiogenic, ST Elevation Myocardial Infarction
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