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Published on: June 12, 2021
Culprit or multivessel revascularisation in ST-elevation myocardial infarction with cardiogenic shock
Jin Sup Park1, Kwang Soo Cha2, Dae Sung Lee1
1Department of Cardiology, Pusan National University Hospital, Busan, South Korea.
Insights
Multivessel revascularisation in ST-elevation myocardial infarction (STEMI) patients experiencing cardiogenic shock significantly reduces in-hospital and all-cause mortality. This approach offers better outcomes compared to only treating the culprit vessel, supporting current treatment guidelines.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- The optimal revascularisation strategy for patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock and multivessel disease (MVD) remains debated.
- Previous studies have not definitively established the benefit of multivessel revascularisation (MVR) over culprit-lesion-only revascularisation (CVR) in this high-risk population.
Purpose of the Study:
- To compare the clinical outcomes of MVR versus CVR in patients presenting with STEMI, cardiogenic shock, and MVD.
- To evaluate the impact of revascularisation strategy on in-hospital mortality, all-cause death, and other major adverse cardiac events.
Main Methods:
- A nationwide, prospective, multicentre registry included 16,620 STEMI patients undergoing primary percutaneous coronary intervention (PCI).
- 510 patients with cardiogenic shock and MVD were selected and divided into CVR (n=386) and MVR (n=124) groups.
- Weighted Cox regression analysis was used to compare in-hospital mortality and all-cause death during a median 194-day follow-up.
Main Results:
- MVR was associated with a significantly lower adjusted risk of in-hospital mortality (2.4% vs 9.3%) and all-cause death (4.8% vs 13.1%) compared to CVR.
- Cardiac death rates were also significantly lower in the MVR group (4.8% vs 9.7%).
- MVR significantly reduced the adjusted risk of the composite endpoint including all-cause death, recurrent myocardial infarction, and any repeat revascularisation (18.1% vs 20.3%).
Conclusions:
- Multivessel revascularisation at the time of primary PCI is associated with improved clinical outcomes in STEMI patients with cardiogenic shock and MVD.
- These findings support the current guideline recommendations for comprehensive revascularisation in this vulnerable patient group.
- The study highlights the importance of addressing all significant coronary lesions in STEMI patients with cardiogenic shock.
Objective:
The value of multivessel revascularisation in cardiogenic shock and multivessel disease (MVD) is still not clear. We compared outcomes following culprit vessel or multivessel revascularisation in patients with ST-elevation myocardial infarction (STEMI), cardiogenic shock and MVD.
Methods:
From 16 620 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) in a nationwide, prospective, multicentre registry between January 2006 and December 2012, 510 eligible patients were selected and divided into culprit vessel revascularisation (n=386, 75.7%) and multivessel revascularisation (n=124, 24.3%) groups. The primary outcomes were inhospital mortality and all-cause death during a median 194-day follow-up. A weighted Cox regression model was constructed to determine the HRs and 95% CIs for outcomes in the two groups.
Results:
Compared with culprit vessel revascularisation, multivessel revascularisation had a significantly lower adjusted risk of inhospital mortality (9.3% vs 2.4%, HR 0.263, 95% CI 0.149 to 0.462, p<0.001) and all-cause death (13.1% vs 4.8%, HR 0.400, 95% CI 0.264 to 0.606, p<0.001), mainly because of fewer cardiac deaths (9.7% vs 4.8%, HR 0.510, 95% CI 0.329 to 0.790, p=0.002). In addition, multivessel revascularisation significantly decreased the adjusted risk of the composite endpoint of all-cause death, recurrent myocardial infarction and any revascularisation (20.3% vs 18.1%, HR 0.728, 95% CI 0.55 to 0.965, p=0.026).
Conclusions:
This study showed that, compared with culprit vessel revascularisation, multivessel revascularisation at the time of primary PCI was associated with better outcomes in patients with STEMI with cardiogenic shock. Our results support the current guidelines regarding revascularisation in these patients.
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