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PCI in NSTEMI, Cardiogenic Shock, and Multivessel CAD
Quick Takes
- Patients with NSTEMI, cardiogenic shock, and multivessel CAD have lower mortality when they undergo multivessel PCI compared to culprit only PCI.
- Multivessel PCI is associated with increased rates of bleeding and new renal failure requiring hemodialysis.
- The best PCI strategy among this patient cohort remains to be determined. Randomized controlled data are needed to determine which patients with NSTEMI and cardiogenic shock benefit from additional revascularization beyond treatment of the culprit vessel.
Study Questions:
What is the best coronary intervention strategy among patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI), cardiogenic shock, and multivessel coronary artery disease (CAD)?
Methods:
Among 25,324 patients in the National Cardiovascular Data Registry CathPCI Registry from July 2009–March 2018, rates of in-hospital procedural outcomes were compared between those undergoing multivessel percutaneous coronary intervention (PCI) versus culprit-vessel-only PCI after 1:1 propensity score matching. Among those aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, the authors compared long-term mortality using proportional hazards analysis.
Results:
Multivessel PCI was performed in 9,791 (38.7%) patients, which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend < 0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI], 2.0-5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%, p < 0.001; odds ratio [OR], 0.85; 95% CI, 0.80-0.91), but a higher risk for bleeding (13.2% vs. 10.8%, p < 0.001; OR, 1.26; 95% CI, 1.15-1.40) and new requirement for dialysis (5.7% vs. 4.6%, p = 0.001; OR, 1.26; 95% CI, 1.10-1.46). Among those surviving to discharge, all-cause mortality was similar for up to 7 years (conditional hazard ratio, 0.95; 95% CI, 0.87-1.03; p = 0.20).
Conclusions:
Nearly 40% of NSTEMI patients with multivessel CAD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater periprocedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.
Perspective:
Debate regarding extent of immediate revascularization in the setting of acute coronary syndromes and cardiogenic shock continues. This nationwide, propensity matched, retrospective analysis from a large registry of patients with NSTEMI and cardiogenic shock suggests that multivessel PCI is associated with significantly less in-hospital mortality. This is offset by increased rates of bleeding and new requirement for hemodialysis. Mortality benefit of multivessel intervention was most prominent among older, nondiabetic patients who needed mechanical support. Interestingly, there did not appear to be a long-term mortality benefit with multivessel PCI over 7 years of follow-up. Randomized controlled data are still needed to determine which patients with NSTEMI and cardiogenic shock benefit from additional revascularization beyond treatment of the culprit vessel.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, 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, CathPCI Registry, Coronary Artery Disease, Geriatrics, Hemorrhage, Hospital Mortality, Myocardial Infarction, Myocardial Revascularization, National Cardiovascular Data Registries, Patient Discharge, Percutaneous Coronary Intervention, Renal Dialysis, Renal Insufficiency, Shock, Cardiogenic
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