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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
Coronary artery bypass grafting versus percutaneous coronary intervention for myocardial infarction complicated by
Nathaniel R Smilowitz1, Carlos L Alviar2, Stuart D Katz2
1Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, NY.
Insights
Coronary artery bypass grafting (CABG) showed lower mortality than percutaneous coronary intervention (PCI) for myocardial infarction (MI) with cardiogenic shock (CS). Further trials are needed to confirm optimal revascularization strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Myocardial infarction (MI) complicated by cardiogenic shock (CS) carries a high mortality rate.
- Early revascularization is crucial for survival, but the best method remains unclear.
- This study compares outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in MI with CS patients.
Purpose of the Study:
- To analyze practice patterns and outcomes of CABG versus PCI in patients with MI complicated by CS.
- To evaluate trends in revascularization strategies over time.
- To determine the association between revascularization method and in-hospital mortality.
Main Methods:
- Retrospective analysis of 386,811 hospitalizations for MI with CS from the US National Inpatient Sample (2002-2014).
- Evaluation of management trends and utilization of PCI and CABG.
- Propensity score matching to compare outcomes between PCI and CABG cohorts.
- Primary outcome: in-hospital all-cause mortality.
Main Results:
- 62.4% of patients with MI and CS received revascularization, with PCI being more common than CABG.
- CABG patients were more likely to have diabetes and less likely to have STEMI compared to PCI patients.
- Overall and propensity-matched analyses showed lower in-hospital mortality with CABG compared to PCI.
Conclusions:
- Coronary artery bypass grafting (CABG) is associated with reduced in-hospital mortality compared to percutaneous coronary intervention (PCI) in patients experiencing myocardial infarction (MI) with cardiogenic shock (CS).
- Residual confounding necessitates further investigation.
- A randomized trial comparing PCI and CABG in this high-risk population with multi-vessel coronary disease is warranted.
Background:
Myocardial infarction (MI) complicated by cardiogenic shock (CS) is associated with high mortality. Early coronary revascularization improves survival, but the optimal mode of revascularization remains uncertain. We sought to characterize practice patterns and outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with MI complicated by CS.
Methods:
Patients hospitalized for MI with CS between 2002 and 2014 were identified from the United States National Inpatient Sample. Trends in management were evaluated over time. Propensity score matching was performed to identify cohorts with similar baseline characteristics and MI presentations who underwent PCI and CABG. The primary outcome was in-hospital all-cause mortality.
Results:
A total of 386,811 hospitalizations for MI with CS were identified; 67% were STEMI. Overall, 62.4% of patients underwent revascularization, with PCI in 44.9%, CABG in 14.1%, and a hybrid approach in 3.4%. Coronary revascularization for MI and CS increased over time, from 51.5% in 2002 to 67.4% in 2014 (P for trend < .001). Patients who underwent CABG were more likely to have diabetes mellitus (35.5% vs. 29.2%, P < .001) and less likely to present with STEMI (48.7% vs. 80.9%, P < .001) than those who underwent PCI. CABG (without PCI) was associated with lower mortality than PCI (without CABG) overall (18.9% vs. 29.0%, P < .001) and in a propensity-matched subgroup of 19,882 patients (19.0% vs. 27.0%, P < .001).
Conclusions:
CABG was associated with lower in-hospital mortality than PCI among patients with MI complicated by CS. Due to the likelihood of residual confounding, a randomized trial of PCI versus CABG in patients with MI, CS, and multi-vessel coronary disease is warranted.
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