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Published on: June 12, 2021
Percutaneous Coronary Intervention in Multivessel Disease and Infarct-Related Cardiogenic Shock: A DanGer Shock
Jasmine M Marquard1, Rasmus P Beske1, Christian Hassager2
1Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Insights
Immediate multivessel percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients with cardiogenic shock and multivessel disease significantly reduced 180-day mortality compared to culprit-only PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Optimal percutaneous coronary intervention (PCI) strategy for ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock and multivessel disease is unclear.
- Multivessel disease is common in STEMI patients experiencing cardiogenic shock.
Purpose of the Study:
- To investigate the association between PCI strategy and clinical outcomes.
- To compare immediate multivessel PCI versus culprit-only PCI in STEMI-related cardiogenic shock with multivessel disease.
Main Methods:
- Exploratory substudy of the DanGer Shock multicenter trial.
- Included STEMI patients with cardiogenic shock and multivessel disease (excluding comatose patients).
- Analyzed outcomes based on as-treated PCI strategy: immediate multivessel PCI or culprit-only PCI.
Main Results:
- Of 221 patients with multivessel disease, 118 (53%) underwent culprit-only PCI and 103 (47%) underwent immediate multivessel PCI.
- All-cause mortality at 180 days was 61% in the culprit-only group versus 50% in the immediate multivessel PCI group.
- Immediate multivessel PCI was associated with a 60% lower odds of all-cause mortality (adjusted OR: 0.40).
Conclusions:
- Immediate multivessel PCI in STEMI-related cardiogenic shock with multivessel disease is associated with significantly lower all-cause mortality.
- Culprit-only PCI strategy showed higher mortality rates in this high-risk patient population.
- Further research may confirm immediate multivessel PCI as a preferred strategy.
Background:
The optimal percutaneous coronary intervention (PCI) strategy in ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock and multivessel disease remains uncertain.
Objectives:
The aim of this study was to investigate the association between PCI strategy and outcomes in STEMI-related cardiogenic shock and multivessel disease.
Methods:
This exploratory substudy of the DanGer Shock (Danish-German Cardiogenic Shock) multicenter trial included patients with STEMI-related cardiogenic shock and multivessel disease, excluding comatose patients resuscitated from cardiac arrest. Multivessel disease was defined by ≥1 nonculprit angiographic stenosis ≥70%. Patients with an isolated left main culprit were excluded. The planned PCI strategy was registered before randomization. All analyses were performed according to as-treated PCI strategy (immediate multivessel PCI or culprit-only PCI). The primary outcome was all-cause mortality within 180 days; secondary outcomes included renal replacement therapy and acute kidney injury.
Results:
Of 355 patients included in the DanGer Shock trial, 221 (72%) had multivessel disease; of these, 118 (53%) were treated with culprit-only PCI and 103 (47%) with immediate multivessel PCI. The median pre-PCI SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were 28 (Q1-Q3: 22-32) and 29 (Q1-Q3: 22-34), respectively. Chronic total occlusion PCI was performed in 6 of 103 patients (6%) treated with immediate multivessel PCI. All-cause mortality was 72 (61%; 95% CI: 52%-70%) in the culprit-only group and 52 (50%; 95% CI: 41%-60%) in the immediate multivessel PCI group (adjusted OR: 0.40; 95% CI: 0.19-0.83) over a median follow-up period of 45 days (Q1-Q3: 2-180 days). Immediate multivessel PCI was not associated with the secondary outcomes. There was no interaction according to randomization allocation and PCI strategy (P = 1.00).
Conclusions:
Immediate multivessel PCI was associated with 60% lower odds of all-cause mortality compared with culprit-only PCI.
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