April 29, 2020
Study Compares Multivessel Versus Culprit-Vessel PCI in Cardiogenic Shock
April 29, 2020—Alejandro Lemor, MD, et al conducted a study to compare outcomes of patients enrolled in the National Cardiogenic Shock Initiative trial who were treated using a percutaneous coronary intervention (PCI) revascularization strategy of either multivessel PCI (MV-PCI) or culprit-vessel PCI (CV-PCI). The study is available online in Journal of the American College of Cardiology (JACC): Cardiovascular Interventions.
According to the investigators, intervening on the nonculprit vessel is controversial in patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS). There are conflicting published reports and a lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS).
This analysis included patients who presented with AMICS to 57 participating hospitals from July 2016 to December 2019. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure.
As summarized in JACC: Cardiovascular Interventions, the analysis was composed of 198 patients with MVCAD, with 126 who underwent MV-PCI (64%) and 72 who underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, previous PCI or coronary artery bypass grafting, and previous history of myocardial infarction.
The investigators reported the following:
- On presentation, patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance.
- At 12 hours postprocedure, MV-PCI patients had significantly worse cardiac performance.
- At 24 hours, the hemometabolic derangements were similar.
- At 24 hours, there were no significant differences in the MV-PCI group versus the CV-PCI group in terms of survival (69.8% vs 65.3% CV-PCI; P = .51) and rates of acute kidney injury (29.9% vs 34.2%; P = .64).
The study showed that in patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safely performed in AMICS in patients supported with MCS, concluded the investigators in JACC: Cardiovascular Interventions.