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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.
Keywords: Acute Coronary Syndrome, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Shock, Cardiogenic, Treatment Outcome, Vascular Diseases
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