Multi- vs Culprit-Vessel Only PCI for AMICS

The rates of acute kidney injury and hospital survival were comparable in patients with multivessel coronary artery disease (CAD) presenting with acute myocardial infarction (AMI) and cardiogenic shock who were on early mechanical circulatory support (MCS) and treated with culprit vessel-only vs multivessel percutaneous coronary intervention (PCI), according to study results published in JACC: Cardiovascular Interventions.

The optimal revascularization approach for patients with multivessel CAD who present with AMI and cardiogenic shock is unclear and without consensus. In this patient population, nonculprit vessel intervention remains controversial, due to limited and conflicting data, particularly for patients treated with MCS.

In this retrospective study, the data of 198 patients (mean age, 64.2±11.7 years; 79.8% men) with multivessel CAD presenting with AMI and cardiogenic shock were examined. Data were collected  from the National Cardiogenic Shock Initiative (ClinicalTrials.gov Identifier: NCT03677180), a multicenter, single-arm, prospective trial examining clinical outcomes in this population for patients treated with early MCS followed by PCI between July 2016 and December 2019. All patients were treated using a standard cardiogenic shock protocol in which MCS was followed by revascularization, with invasive hemodynamic monitoring.

Hospital survival rate was the primary study outcome, and the rate of acute kidney injury and duration of hospital stay were secondary outcomes.

In this cohort, 126 (63.6%) and 72 (36.4%) patients underwent multivessel and culprit vessel-only PCI, respectively. Most demographic and clinical variables were similar between the treatment groups, but patients treated with multivessel vs culprit vessel-only PCI tended to be older, more often men, to have poorer lactate clearance, more severe cardiac output impairment at baseline, and poorer cardiac function 12 hours post-PCI (cardiac power output, 0.79 vs 0.91 watts, respectively; P =.03).

However, 24 hours post-PCI, most hemometabolic abnormalities were comparable between the treatment groups. The rates of hospital survival (69.8% vs 65.3%; P = .51) and acute kidney injury (29.9% vs 34.2%; P = .64) and the median hospital stay duration (10 vs 8 days; P =.50) were comparable in patients treated with multi- vs culprit vessel-only PCI, respectively.

Study limitations include its observational design, single-arm setup, possible selection bias, and small sample size that may have led to an underpowering of difference detection.

“Selective non-culprit PCI can be safely performed in patients with [AMI and cardiogenic shock] supported with MCS. Further studies are needed to assess long-term outcomes of this treatment strategy,” noted the authors.

Reference

Lemor A, Basir MB, Patel K, et al. Multi- versus culprit-vessel percutaneous coronary intervention in cardiogenic shock. JACC Cardiovasc Interv. April 2020. doi:10.1016/j.jcin.2020.03.012