Complete Revascularization Is Beneficial in Acute MI with Cardiogenic Shock

Around half of all cases of ST-segment elevation acute myocardial infarction (STEMI) come alongside lesions in another vessel, for which the current strategy is complete revascularization in one or two steps. However, there are no large-scale studies analyzing patients who also present cardiogenic shock; we only have observational studies with inconclusive results influenced by several confounding variables.

This study analyzed the KAMIR-NIH Registry, which included 13,104 patients. Among them, 659 experienced STEMI with cardiogenic shock: 399 (60.5%) underwent infarction-related-artery (IRA)-only angioplasty and 260 (39.5%) were treated with multivessel angioplasty.

Populations were similar: the mean age was 67 years old, 40% of all patients had diabetes, 37% experienced renal impairment, 8% had experienced prior acute myocardial infarction, and 35.8% had sustained cardiac arrest.

Door-to-balloon time was 62 minutes; the culprit vessel was the left main coronary artery in 9.4% of all cases; patients received glycoprotein IIb/IIIa in 23.4% of all cases, and underwent aspiration thrombectomy in 31.5% of all cases.

Read also: Surprising Prognosis for Normal ACS.

Most stents used were second-generation drug-eluting stents (DES). The IRA-only group received 1.1 stents, while the multivessel group received 2.24. Among patients in the multivessel group, 157 patients (60.4%) underwent mulivessel revascularization in a single procedure, while the rest had a second procedure during the same hospital stay. Complete revascularization was achieved in 65.8% of patients.

At 30 days, the rates of all-cause mortality, acute myocardial infarction, or repeat revascularization were lower among patients in the multivessel group.

The follow-up was 359 days (171-383). All-cause mortality was lower among the multivessel group (21.3% vs. 31.7%; p = 0.001). The composite endpoint of death, acute myocardial infarction, or revascularization was lower among the multivessel group, driven by lower rates of mortality and non-culprit vessel revascularization.

Read also: Incomplete Revascularization Does Not Mean the Same Thing for All Patients.

Patients who underwent multivessel angioplasty with complete revascularization presented lower rates of mortality, acute myocardial infarction, and revascularization than patients with incomplete revascularization.

Multivessel revascularization was an independent predictor of reduced all-cause death, acute myocardial infarction, or revascularization.

Conclusion

In patients with acute myocardial infarction and multivessel lesions with cardiogenic shock, multivessel angioplasty was associated with a significantly lower risk of death and non-culprit-artery revascularization. These data suggest that multivessel angioplasty with complete revascularization is a reasonable strategy for the improvement of outcomes among patients with acute myocardial infarction and cardiogenic shock.

Editorial Comment

The presence of cardiogenic shock alongside acute myocardial infarction is an uncommon but complex scenario: most times, we are faced with multivessel lesions and chronic occlusions associated with high mortality rates.

Revascularization of all lesions (not only the culprit vessel), especially complete revascularization, is associated with lower rates of mortality and of major adverse cardiac events (MACE). However, such revascularization must be analyzed on a case-by-case basis: whether it should be carried out in a single procedure, if there is no hemodynamic improvement after primary angioplasty, or in a second procedure during the same hospital stay.

Read also: The CULPRIT-SHOCK Study Is Finally Published in NEJM and It Is Bound to Change Guidelines.

Furthermore, for this patient group, we must strive to achieve the most complete revascularization possible, since this improves patient prognosis significantly.

We should also start giving serious consideration to the use of ventricular assistant devices, despite their many well-known limitations, generally marked by their lack of availability and high costs.

Courtesy of Dr. Carlos Fava.

Original title: Multivessel Percutaneous Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction with Cardiogenic Shock.

Reference: Joo Myung Lee et al. J Am Coll Cardiol 2018;71:844-565.

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