Abstract and Introduction
Abstract
Objective The value of multivessel revascularisation in cardiogenic shock and multivessel disease (MVD) is still not clear. We compared outcomes following culprit vessel or multivessel revascularisation in patients with ST-elevation myocardial infarction (STEMI), cardiogenic shock and MVD.
Methods From 16 620 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) in a nationwide, prospective, multicentre registry between January 2006 and December 2012, 510 eligible patients were selected and divided into culprit vessel revascularisation (n=386, 75.7%) and multivessel revascularisation (n=124, 24.3%) groups. The primary outcomes were inhospital mortality and all-cause death during a median 194-day follow-up. A weighted Cox regression model was constructed to determine the HRs and 95% CIs for outcomes in the two groups.
Results Compared with culprit vessel revascularisation, multivessel revascularisation had a significantly lower adjusted risk of inhospital mortality (9.3% vs 2.4%, HR 0.263, 95% CI 0.149 to 0.462, p<0.001) and all-cause death (13.1% vs 4.8%, HR 0.400, 95% CI 0.264 to 0.606, p<0.001), mainly because of fewer cardiac deaths (9.7% vs 4.8%, HR 0.510, 95% CI 0.329 to 0.790, p=0.002). In addition, multivessel revascularisation significantly decreased the adjusted risk of the composite endpoint of all-cause death, recurrent myocardial infarction and any revascularisation (20.3% vs 18.1%, HR 0.728, 95% CI 0.55 to 0.965, p=0.026).
Conclusions This study showed that, compared with culprit vessel revascularisation, multivessel revascularisation at the time of primary PCI was associated with better outcomes in patients with STEMI with cardiogenic shock. Our results support the current guidelines regarding revascularisation in these patients.
Introduction
Patients with acute ST-elevation myocardial infarction (STEMI) and cardiogenic shock exhibit increased morbidity and mortality during hospitalisation. Cardiogenic shock complicates 5%–10% of all STEMI cases. To improve outcomes, early revascularisation in the infarct-related artery is strongly considered. However, primary percutaneous coronary intervention (PCI) in multivessel coronary artery disease (MVD) may present difficulties. Although current guidelines recommend culprit vessel revascularisation during primary PCI in patients with STEMI, multivessel revascularisation can be performed to improve clinical outcomes in patients with STEMI with persistent cardiogenic shock. However, given its potential disadvantages, including greater risk of stent thrombosis, ongoing ischaemia, contrast-induced nephropathy (CIN) and longer radiation exposure, the decision to do multivessel revascularisation during primary PCI continues to be controversial and the support for multivessel PCI in patients with STEMI and cardiogenic shock is limited.
Thus, we compared the clinical outcomes of patients with STEMI, cardiogenic shock and MVD who were treated with culprit or multivessel revascularisation.