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

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Highlights

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    Patients with Cardiogenic Shock (CS) presenting with STEMI still have high mortality rates.

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    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.

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    This was an observational study of 21,210 STEMI patients between 2005 and 2015 at 8 Heart Attack Centres in London, UK.

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    We found that complete revascularisation appears to be associated with better outcomes compared to culprit vessel only intervention.

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    This supports on-going clinical trials in this area and provides further evidence of the association of complete revascularisation in STEMI with good outcomes.

Abstract

Background

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.

Methods and results

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.

Conclusion

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.

Section snippets

Background

Cardiogenic shock (CS), which still complicates 7–10% of patients with acute myocardial infarction (AMI), continues to be associated with high mortality (40–50%) [1,2]. Early revascularisation therapy has been shown to improve prognosis of patients with AMI complicated by CS [3]. Approximately 75% of patients with CS present with multi-vessel coronary artery disease [3,4], with these patients having a higher mortality compared to patients with single vessel disease [[3], [4], [5], [6]]. Recent

Methods

This was an observational cohort study using a merged database from the 8 London Heart Attack Centres who collect data based on the British Cardiac Intervention Society (BCIS) dataset.

Results

The study population consisted of 1058 patients with a mean age of 67.29 years and 20.8% being women. 51.6% of the patients had hypertension, 41.2% had dyslipidemia, 47.0% were active or ex-smokers, and 22.0% had diabetes. As expected, for patients with cardiogenic shock, the majority of PCI procedures were performed through the femoral route, accounting for 85.0% of procedures throughout the study period.

Overall 1058 (55.4%) of patients with cardiogenic shock had multi-vessel disease. Of these

Discussion

This large study of over ≫1000 AMI patients with CS found that immediate complete revascularisation appears to be associated with better outcomes compared to culprit only intervention in this patient group. In our study we saw no unadjusted difference between the complete and culprit only groups but after adjusting for a number of significant differences in baseline characteristics between the groups, this study demonstrated that complete revascularisation during primary PCI in patients with CS

Conclusion

Cardiogenic shock remains a major cause of mortality after AMI. Due to the high mortality rates in this large cohort of patients with AMI complicated by cardiogenic shock, complete revascularisation appears to be associated with better outcomes compared to culprit vessel intervention. However, this is only hypothesis-generating and a randomised-controlled trial should help to address these issues.

Funding statement

This work was not funded by any funding body.

Declaration of Competing Interest

None declared from any of the authors.

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