December 21, 2017
PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock
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.