Patients with acute myocardial infarction (AMI) and cardiogenic shock increasingly undergo multivessel PCI and tend to have poorer outcomes than patients who undergo culprit-vessel PCI, according to a study published Aug. 24 in JAMA Internal Medicine. The study is part of ACC's Research to Practice (R2P) initiative, which identifies impactful cardiovascular research and analyzes its implications for contemporary clinical practice using ACC's NCDR clinical registries.

Rohan Khera, MD, MS, et al., used data from ACC's CathPCI Registry to evaluate use of multivessel PCI vs. culprit-vessel PCI and outcomes for both among U.S. patients with AMI and cardiogenic shock between 2009 and 2018. The study's primary outcome was in-hospital mortality. The researchers also looked at temporal trends and hospital variations in PCI strategies. For secondary outcomes, the researchers analyzed the association between PCI strategy and postdischarge outcomes in a subset of patients who were Medicare beneficiaries.

The final study cohort consisted of 64,301 patients with AMI and cardiogenic shock. Of these, 48,943 patients (76.1%) presented with STEMI, and 15,358 (23.9%) presented with NSTEMI. Among all patients, 22,418 patients (34.9%) received multivessel PCI and 41,883 (65.1%) underwent culprit vessel-only PCI. Among STEMI patients, 15,394 (31.5%) received multivessel PCI. During the study period, use of multivessel PCI increased by 55% in patients with cardiogenic shock, 55% in STEMI patients and 53% in AMI patients overall.

Among patients with STEMI and cardiogenic shock, multivessel PCI was associated with higher in-hospital mortality (risk-adjusted odds ratio [OR], 1.11; 95% confidence interval [CI], 1.06-1.16; p<0.001). Among the overall AMI population, including both STEMI and NSTEMI patients, multivessel PCI was associated with lower risk-adjusted mortality (risk-adjusted OR, 0.96; 95% CI, 0.92-0.99; p=0.02). In the overall AMI population, after adjusting for pre-PCI characteristics – including demographics, comorbidities, clinical presentation in the catheterization laboratory and disease severity – use of multivessel PCI was associated with increased odds of one or more complications vs. culprit-only PCI.

There were 1,336 hospitals in the hospital-level analysis. At these hospitals, the median rate of multivessel PCI use among eligible patients was 32.7%, with wide variations across hospitals. Hospitals in the higher quartiles of multivessel PCI use were more often urban teaching hospitals, had larger bed sizes and higher annual PCI volumes vs. hospitals in lower quartiles.

In the subset of 18,142 Medicare beneficiaries who were followed long-term, one-year mortality was 51.5% among patients who received multivessel PCI vs. 49.8% in patients who underwent culprit vessel-only PCI. There were no significant differences in the two groups in one-year readmission rates, both overall or for recurrent AMI.

According to the researchers, the study "highlights opportunities to improve care practices" for patients with AMI and cardiogenic shock. They conclude that multivessel PCI is associated with poorer outcomes and in-hospital morality, particularly in STEMI patients, without evidence of improved long-term outcomes.

In an accompanying editorial, Colette DeJong, MD, and Rita F. Redberg, MD, FACC, write that the findings are a reminder that "interventions that are conceptually sound and delivered with the best of intentions do not always stand up to empirical testing and may carry unintended harms." "Despite our good intentions, it is clear that primary nonculprit PCI for patients with acute MI in cardiogenic shock does not benefit and can harm, and the practice should be abandoned for patient safety," they conclude.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Acute Heart Failure, Interventions and Vascular Medicine, Chronic Angina

Keywords: Shock, Cardiogenic, ST Elevation Myocardial Infarction, Medicare, Patient Safety, Percutaneous Coronary Intervention, Patient Readmission, Patient Discharge, Myocardial Infarction, Registries, National Cardiovascular Data Registries, CathPCI Registry

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