Complete Versus Culprit only Revascularisation in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction: Incidence and Outcomes from the London Heart Attack Group

• Published in: Cardiovascular revascularization medicine Vol. 21; no. 3; pp. 350 - 358
• Main Authors: Rathod, Krishnaraj S., Koganti, Sudheer, Jain, Ajay K., Rakhit, Roby, Dalby, Miles C., Lockie, Tim, Kalra, Sundeep, Malik, Iqbal S., Knight, Charles J., Whitbread, Mark, Mathur, Anthony, Firoozi, Sam, Bogle, Richard, Redwood, Simon, MacCarthy, Philip A., Sirker, Alexander, O'Mahony, Constantinos, Wragg, Andrew, Jones, Daniel A.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-03-2020
• Subjects: Aged; Aged, 80 and over; Cardiogenic shock; Coronary Artery Disease - complications; Coronary Artery Disease - diagnosis; Coronary Artery Disease - mortality; Coronary Artery Disease - therapy; Databases, Factual; Female; Humans; London; Male; Middle Aged; Multi-vessel intervention; Myocardial infarction; Percutaneous Coronary Intervention - adverse effects; Percutaneous Coronary Intervention - mortality; Primary PCI; Risk Factors; Shock, Cardiogenic - diagnosis; Shock, Cardiogenic - etiology; Shock, Cardiogenic - mortality; ST Elevation Myocardial Infarction - diagnosis; ST Elevation Myocardial Infarction - etiology; ST Elevation Myocardial Infarction - mortality; ST Elevation Myocardial Infarction - therapy; Time Factors; Treatment Outcome; London; Multi-vessel intervention; Myocardial infarction; Primary PCI; Cardiogenic shock
• ISSN: 1553-8389; 1878-0938
• DOI: 10.1016/j.carrev.2019.06.007

Despite advances in technology, patients with Cardiogenic Shock (CS) presenting with ST-segment myocardial infarction (STEMI) still have a poor prognosis with high mortality rates. A large proportion of these patients have multi-vessel coronary artery disease, the treatment of which is still unclear. We aimed to assess the trends in management of CS patients with multi-vessel disease (MVD), particularly looking at the incidence and outcomes of complete revascularisation compared to culprit vessel only.
We undertook an observational cohort study of 21,210 STEMI patients treated between 2005 and 2015 at the 8 Heart Attack Centres in London, UK. Patients' details were recorded prospectively into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. 1058 patients presented with CS and MVD. Primary outcome was all-cause mortality. Patients were followed-up for a median of 4.1 years (IQR range: 2.2–5.8 years).
497 (47.0%) patients underwent complete revascularisation during primary PCI for CS with stable rates seen over time. These patients were more likely to be male, hypertensive and more likely to have poor LV function compared to the culprit vessel intervention group. Although crude, in hospital major adverse cardiac events (MACE) rates were similar (40.8% vs. 36.0%, p = 0.558) between the two groups. Kaplan-Meier analysis demonstrated no significant differences in mortality rates between the two groups (53.8% complete revascularisation vs. 46.8% culprit vessel intervention, p = 0.252) during the follow-up period. After multivariate cox analysis (HR 0.69 95% CI (0.44–0.98)) and the use of propensity matching (HR: 0.81 95% CI: 0.62–0.97) complete revascularisation was associated with reduced mortality. A number of co-variates were included in the model, including age, gender, diabetes, hypertension, hypercholesterolaemia, previous PCI, previous MI, chronic renal failure, Anterior infarct, number of treated vessels, pre-procedure TIMI flow, procedural success and GP IIb/IIIA use.
In a contemporary observational series of CS patients with MVD, complete revascularisation appears to be associated with better outcomes compared to culprit vessel only intervention. This supports on-going clinical trials in this area and provides further evidence of the association of complete revascularisation in STEMI with good outcomes.
•Patients with Cardiogenic Shock (CS) presenting with STEMI still have high mortality rates.•This study aimed to assess the trends in management of CS patients with multi-vessel disease (MVD), particularly looking at the incidence and outcomes of complete revascularisation compared to culprit vessel only.•This was an observational study of 21,210 STEMI patients between 2005 and 2015 at 8 Heart Attack Centres in London, UK.•We found that complete revascularisation appears to be associated with better outcomes compared to culprit vessel only intervention.•This supports on-going clinical trials in this area and provides further evidence of the association of complete revascularisation in STEMI with good outcomes.