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Published on: June 12, 2021
Clinical Outcomes According to ECG Presentations in Infarct-Related Cardiogenic Shock in the Culprit Lesion Only PCI
Michel Zeitouni1, Ibrahim Akin2, Steffen Desch3
1ACTION Study Group, Institut de Cardiologie (AP-HP), INSERM UMRS_1166, Sorbonne Université, Paris.
Insights
In acute myocardial infarction (AMI) with cardiogenic shock, electrocardiogram (ECG) presentations like non-ST-segment elevation myocardial infarction (NSTEMI) and left bundle branch block myocardial infarction (LBBBMI) do not independently affect mortality compared to ST-segment elevation myocardial infarction (STEMI). Treatment strategies remain consistent across all ECG types.
Area of Science:
- Cardiology
- Acute Myocardial Infarction (AMI)
- Cardiogenic Shock
- Electrocardiogram (ECG) Presentations
Background:
- The prognostic impact of different electrocardiogram (ECG) presentations in patients experiencing acute myocardial infarction (AMI) complicated by cardiogenic shock remains unclear.
- Existing research has not fully elucidated whether specific ECG findings influence outcomes or the effectiveness of revascularization strategies in this high-risk population.
Purpose of the Study:
- To compare outcomes and the effect of revascularization strategies in patients with cardiogenic shock presenting with non-ST-segment elevation myocardial infarction (NSTEMI) or left bundle branch block myocardial infarction (LBBBMI) versus ST-segment elevation myocardial infarction (STEMI).
- To evaluate the interaction between ECG presentation and revascularization strategy efficacy on mortality.
Main Methods:
- Analysis of 665 patients from the CULPRIT-SHOCK trial who experienced cardiogenic shock.
- Comparison of 30-day and 1-year all-cause mortality between patients with STEMI, NSTEMI, and LBBBMI.
- Assessment of the interaction between ECG presentation and the impact of revascularization strategies on patient outcomes.
Main Results:
- No significant difference in 30-day mortality was observed between NSTEMI and STEMI (48.7% vs. 43.0%), nor between LBBBMI and STEMI (59.2% vs. 43.0%).
- While univariate analysis showed higher 1-year mortality for NSTEMI and LBBBMI, ECG presentation was not an independent predictor of mortality after adjustment.
- Crucially, ECG presentation did not modify the treatment effect of revascularization strategies on either 30-day or 1-year mortality (P > 0.90 for interaction).
Conclusions:
- In cardiogenic shock, NSTEMI and LBBBMI presentations are associated with higher-risk profiles but are not independent risk factors for mortality compared to STEMI.
- The effectiveness of revascularization strategies is consistent across different ECG presentations of AMI in patients with cardiogenic shock.
- These findings support the use of culprit-lesion-only percutaneous coronary intervention as a preferred strategy for all AMI presentations within the cardiogenic shock spectrum.
Background:
The impact of ECG presentations of acute myocardial infarction (AMI) in cardiogenic shock is unknown.
Research Question:
In myocardial infarction with cardiogenic shock, is there a difference in the outcomes and effect of revascularization strategies between non-ST-segment elevation myocardial infarction (NSTEMI) and left bundle branch block myocardial infarction (LBBBMI) vs ST-segment elevation myocardial infarction (STEMI)?
Study Design And Methods:
Cardiogenic shock patients from the CULPRIT-SHOCK trial with NSTEMI or LBBBMI were compared with STEMI patients for 30-day and 1-year all-cause mortality. The interaction between ECG presentation and the effect of revascularization strategies on outcomes was evaluated.
Results:
Of 665 cardiogenic shock patients analyzed, 55.9% demonstrated STEMI, 29.3% demonstrated NSTEMI, and 14.7% demonstrated LBBBMI. Patients differed in mean age (68.0 years in STEMI patients, 71.0 years in NSTEMI patients, and 73.5 years in LBBBMI patients; P = .015), cardiovascular risk factors, and angiographic severity. No difference was found in the 30-day risk of death between NSTEMI and STEMI patients (48.7% vs 43.0%; adjusted OR [aOR], 1.05; 95% CI, 0.66-1.67; P = .85), nor between LBBBMI and STEMI patients (59.2% vs 43.0%; aOR, 1.31; 95% CI, 0.73-2.34; P = .36). Although the univariate risk of death by 1 year was higher in NSTEMI and LBBBMI patients compared with STEMI patients, ECG presentation was not an independent risk factor of mortality after adjustment (NSTEMI vs STEMI: 56.4% vs 46.8%; aOR, 1.21; 95% CI, 0.76-1.92; P = .42; LBBBMI vs STEMI: 69.4% vs 46.8%; aOR, 1.59; 95% CI, 0.89-2.84; P = .12). ECG presentation did not modify the effect of the revascularization strategy on 30-day and 1-year mortality (P = .91 and P = .97 for interaction).
Interpretation:
In patients with cardiogenic shock, NSTEMI and LBBBMI presentations reflect higher-risk profiles than STEMI presentations, but are not independent risk factors of mortality. ECG presentations did not modify the treatment effect, supporting culprit-lesion-only percutaneous coronary intervention as the preferred strategy across the AMI spectrum.
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