Complete revascularisation may increase survival in NSTEMI with cardiogenic shock, JACC study.

Most previous studies focussing on the benefit of complete vs. culprit-only PCI in myocardial infarction (MI) complicated by cardiogenic shock (like CULPRIT-SHOCK trial , KAMIR-NIH registry) had either both STEMI and NSTEMI patients or only the former category. Thus the outcomes in NSTEMI population have not been explored in any dedicated study.

Omer et al, in this month's issue of JACC, have presented results from their study done to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel–only percutaneous coronary intervention (PCI) in patients with NSTEMI, multivessed disease (MVD) and cardiogenic shock. Authors have found that multivessel PCI was associated with lower in-hospital mortality but greater periprocedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.

25,324 patients were included from the National Cardiovascular Data Registry Cath PCI Registry from July 2009 to March 2018,the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel–only PCI after 1:1 propensity score matching. Among patients > 65 years of age matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis.

The primary outcome of this study was all-cause mortality. Secondary outcomes included the occurrence of procedural bleeding events within 72 h, stroke, new requirement for dialysis, and peri- cardial tamponade. Patients were classified, on the basis of the index procedure, into culprit vessel– only PCI intervention if PCI of only 1 vessel was attempted or the multivessel PCI group if the culprit and at least 1 additional vessel were intervened upon.

The study generated the following important results:

1. Nearly 2 in 5 patients underwent multivessel PCI during the study period, with an increasing prevalence over time.

2. Compared with culprit-vessel PCI, those undergoing multivessel PCI had a clinically important 3.5% lower absolute rate of in-hospital mortality but higher rates of periprocedural bleeding and acute renal failure requiring dialysis.

3. Among those surviving to hospital discharge, multivessel PCI did not confer additional reductions in long-term mortality for up to 7 years of follow-up.

The endpoint of mortality in particular seems significantly affected by the very high risk profile of the multivessel PCI cohort hence propensity score matching was done and after adjustment for potential confounders (including left main disease and complex class C lesion), authors found that multivessel PCI was associated with statistically significant lower in-hospital mortality. Increased rates of dialysis in the multivessel PCI group can be explained by more volume of IV contrast in the procedure.

Among those surviving to hospital discharge, the risk for all-cause mortality did not differ between the 2 groups over the 7-year follow-up period. These results are consistent with the 1-year outcome of the CULPRIT-SHOCK trial.

One notable derivation from this study is that despite higher rates of procedural complications and dialysis, the long term outcomes remain unaffected, suggesting that the acute impact on outcomes should be most influential in clinical decision making.

"These data highlight the complexity of individualized decision making for patients with NSTEMI and multi-vessel disease complicated by cardiogenic shock until more definitive prospective trials are conducted", concluded the authors.

Source: JACC Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non–ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. JACC Cardiovasc Interv 2021 doi: 10.1016/j.jcin.2021.02.021