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December 21, 2017

PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock

Lara Samkary

Summarized by: 

What was the research question?

  • Does culprit-lesion-only PCI approach decrease 30-day mortality in patients with multi-coronary vessel disease, acute myocardial infarction and cardiogenic shock when compared to immediate multivessel PCI?

How did they do it?

  • A multicenter, randomized, unblinded trial conducted at several European centers.

  • 706 clinically matched patients with acute MI complicated by cardiogenic shock were enrolled.

  • Patients were screened and randomly assigned to one of two initial revascularization strategies: PCI of the culprit lesion only (355 patients) or immediate multivessel PCI (351 patients).

  • The primary outcome was a composite of 30-day mortality from any cause or severe renal failure requiring renal-replacement therapy.

  • Secondary outcomes encompassed recurrent cardiogenic complications, hemodynamic stabilization time, catecholamine therapy and mechanical ventilation usage and duration, ICU stay length, and SAPS-II score.

What did they find?

  • 30-day mortality or renal replacement therapy was significantly lower in the Culprit-lesion-only PCI compared to the multivessel PCI. (45.9% vs. 55.4%; relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P = 0.01).

  • Culprit-lesion-only PCI had a significantly lower rate of 30-day mortality from any cause than multivessel PCI (43.3% vs. 51.6%; relative risk, 0.84; 95% CI, 0.72 to 0.98; P = 0.03)

  • The rate of renal-replacement therapy did not differ significantly between the two groups. (11.6% and 16.4%, respectively; relative risk, 0.71; 95% CI, 0.49      to 1.03; P=0.07)

  • No significant difference was present in the rates of secondary outcomes between the two groups.

What are the limitations?

  • Due to the nature of the intervention, blinding was not possible.

  • Due to the complex clinical judgments required to manage cardiogenic shock, some bias may persist during treatment.

  • 75 participants switched between the treatments for various reasons, indicating that the treatment plan should be adjusted based on clinical circumstances.

What does it mean?

  • Culprit-lesion-only PCI demonstrated a significant decrease in 30-day all-cause mortality in patients with acute MI with cardiogenic shock compared to immediate multivessel PCI.

  • The study supports culprit-lesion-only PCI with progressive staged revascularization of nonculprit lesions as the preferable initial revascularization strategy in such patients.

  • The therapeutic strategy should, however, constantly be tailored to the clinical situation of the patient.


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