In the Journals

Culprit lesion-only PCI may be best in acute MI with cardiogenic shock

Amartya Kundu
Amartya Kundu

In patients with acute MI complicated by cardiogenic shock, multivessel PCI yielded similar outcomes compared with culprit lesion-only PCI, but may carry a higher risk of renal failure, researchers reported in Catheterization and Cardiovascular Interventions.

“Our pooled analysis showed that there was no additional benefit in either short- or long-term efficacy outcomes with complete revascularization/multivessel PCI, compared with culprit lesion-only PCI, in patients with acute MI and cardiogenic shock. Moreover, multivessel PCI was associated with a statistically significant increased risk of developing acute kidney injury,” Amartya Kundu, MD, from the division of CV medicine at the University of Massachusetts Medical School in Worcester, told Cardiology Today’s Intervention.

Cardiogenic shock remains one of the “most feared and devastating” complications of acute MI, with in-hospital mortality rates estimated to be as high as 50%, Kundu said. Most patients with acute MI who present with cardiogenic shock have underlying multivessel CAD.

“There has been a lot of debate recently regarding the optimal revascularization strategy in these patients, particularly with respect to management of non-culprit lesions. While the decision regarding which approach to pursue has very important clinical implications, the current American College of Cardiology/American Heart Association guidelines give no specific recommendations on this topic,” Kundu said. “As there have been conflicting results in recently published studies on whether complete revascularization leads to better outcomes in this high-risk group of patients, we decided to investigate further by performing a comprehensive meta-analysis, comparing outcomes with multivessel PCI vs. culprit lesion-only PCI in patients with acute MI and cardiogenic shock.”

No added benefit of multivessel PCI

Kundu and colleagues evaluated 14 studies — 13 observational studies and one randomized clinical trial — including 8,522 patients that compared culprit lesion-only PCI with multivessel PCI. About three-quarters of patients underwent culprit lesion-only PCI and about one-quarter underwent multivessel PCI.

The primary outcome was short-term all-cause mortality — death within 30 days of the procedure — and secondary outcomes included repeat revascularization, myocardial reinfarction and long-term mortality — death 6 months or more after the index hospitalization. Safety outcomes included stroke, acute renal failure and bleeding.

After multivessel PCI compared with culprit lesion-only PCI, the likelihood of death from any cause was similar in both the short term (OR = 1.14; 95% CI, 0.9-1.43) and the long term (OR = 0.94; 95% CI, 0.68-1.28). The risks for myocardial reinfarction (OR = 1.19; 95% CI, 0.76-1.86) and repeat revascularization (OR = 0.79; 95% CI, 0.41-1.55) were also comparable.

With multivessel PCI compared with culprit lesion-only PCI, the risks for bleeding (OR = 1.13; 95% CI, 0.91-1.4) and stroke (OR = 1.28; 95% CI, 0.84-1.96) were also comparable. However, risk for renal failure was higher with multivessel PCI than with culprit lesion-only PCI (OR = 1.32; 95% CI, 1.05-1.65).

“These results were not very surprising as multivessel PCI in hemodynamically unstable patients is a challenging procedure, with an increased risk of procedural complications such as acute vessel occlusion, stent thrombosis, loss of side-branch and distal embolization. Moreover, the higher doses of contrast used leads to an increased risk of developing renal failure secondary to contrast-induced nephropathy. The detrimental effects of these adverse outcomes likely overshadow any potential benefits that may be seen with complete revascularization,” Kundu told Cardiology Today’s Intervention.

Consideration of other factors

Despite these findings, multivessel PCI may still be a viable treatment option in patients with acute MI and cardiogenic shock, but more research is needed, according to Kundu.

“First, with respect to multivessel PCI, a staged approach, as opposed to complete revascularization during the index procedure, theoretically carries a lower risk of developing renal failure and it will be interesting to see whether the benefits of complete revascularization — as has been shown in hemodynamically stable patients with acute MI — are seen with this approach. However, at present, there are no randomized studies comparing outcomes separately between culprit lesion-only PCI, staged multivessel PCI and single-setting multivessel PCI in patients with acute MI and cardiogenic shock,” he said.

“Second, with increasing routine use of mechanical circulatory support devices during complex interventions, it will be interesting to see whether use of such hemodynamic support devices independently affects clinical outcomes with either revascularization strategy.”

Consequently, more randomized trials and real-world or registry studies would be beneficial and help better identify the optimal management strategy in this high-risk group of patients, according to Kundu.

For now, though, the results from this meta-analysis suggest that multivessel PCI provides no additional benefit regarding short- or long-term outcomes, he noted.

“However, the optimal revascularization strategy should be decided on an individual basis after taking into account a number of factors such as age, comorbid medical conditions, the degree of hemodynamic deterioration and the complexity of underlying coronary lesions,” Kundu told Cardiology Today’s Intervention. “In clinical practice, the decision to perform complete revascularization in patients with shock is often influenced by the results of initial culprit lesion-only PCI. Interventionalists may be tempted to forego additional revascularization when significant hemodynamic improvement occurs after successful culprit lesion-only PCI. Conversely, patients with continued hemodynamic instability after culprit lesion-only PCI are more likely to undergo further multivessel PCI as a salvage procedure.” – by Melissa Foster

For more information:

Amartya Kundu, MD, can be reached at amartya.kundu@umassmemorial.org.

Disclosure: The authors report no relevant financial disclosures.

Amartya Kundu
Amartya Kundu

In patients with acute MI complicated by cardiogenic shock, multivessel PCI yielded similar outcomes compared with culprit lesion-only PCI, but may carry a higher risk of renal failure, researchers reported in Catheterization and Cardiovascular Interventions.

“Our pooled analysis showed that there was no additional benefit in either short- or long-term efficacy outcomes with complete revascularization/multivessel PCI, compared with culprit lesion-only PCI, in patients with acute MI and cardiogenic shock. Moreover, multivessel PCI was associated with a statistically significant increased risk of developing acute kidney injury,” Amartya Kundu, MD, from the division of CV medicine at the University of Massachusetts Medical School in Worcester, told Cardiology Today’s Intervention.

Cardiogenic shock remains one of the “most feared and devastating” complications of acute MI, with in-hospital mortality rates estimated to be as high as 50%, Kundu said. Most patients with acute MI who present with cardiogenic shock have underlying multivessel CAD.

“There has been a lot of debate recently regarding the optimal revascularization strategy in these patients, particularly with respect to management of non-culprit lesions. While the decision regarding which approach to pursue has very important clinical implications, the current American College of Cardiology/American Heart Association guidelines give no specific recommendations on this topic,” Kundu said. “As there have been conflicting results in recently published studies on whether complete revascularization leads to better outcomes in this high-risk group of patients, we decided to investigate further by performing a comprehensive meta-analysis, comparing outcomes with multivessel PCI vs. culprit lesion-only PCI in patients with acute MI and cardiogenic shock.”

No added benefit of multivessel PCI

Kundu and colleagues evaluated 14 studies — 13 observational studies and one randomized clinical trial — including 8,522 patients that compared culprit lesion-only PCI with multivessel PCI. About three-quarters of patients underwent culprit lesion-only PCI and about one-quarter underwent multivessel PCI.

The primary outcome was short-term all-cause mortality — death within 30 days of the procedure — and secondary outcomes included repeat revascularization, myocardial reinfarction and long-term mortality — death 6 months or more after the index hospitalization. Safety outcomes included stroke, acute renal failure and bleeding.

After multivessel PCI compared with culprit lesion-only PCI, the likelihood of death from any cause was similar in both the short term (OR = 1.14; 95% CI, 0.9-1.43) and the long term (OR = 0.94; 95% CI, 0.68-1.28). The risks for myocardial reinfarction (OR = 1.19; 95% CI, 0.76-1.86) and repeat revascularization (OR = 0.79; 95% CI, 0.41-1.55) were also comparable.

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With multivessel PCI compared with culprit lesion-only PCI, the risks for bleeding (OR = 1.13; 95% CI, 0.91-1.4) and stroke (OR = 1.28; 95% CI, 0.84-1.96) were also comparable. However, risk for renal failure was higher with multivessel PCI than with culprit lesion-only PCI (OR = 1.32; 95% CI, 1.05-1.65).

“These results were not very surprising as multivessel PCI in hemodynamically unstable patients is a challenging procedure, with an increased risk of procedural complications such as acute vessel occlusion, stent thrombosis, loss of side-branch and distal embolization. Moreover, the higher doses of contrast used leads to an increased risk of developing renal failure secondary to contrast-induced nephropathy. The detrimental effects of these adverse outcomes likely overshadow any potential benefits that may be seen with complete revascularization,” Kundu told Cardiology Today’s Intervention.

Consideration of other factors

Despite these findings, multivessel PCI may still be a viable treatment option in patients with acute MI and cardiogenic shock, but more research is needed, according to Kundu.

“First, with respect to multivessel PCI, a staged approach, as opposed to complete revascularization during the index procedure, theoretically carries a lower risk of developing renal failure and it will be interesting to see whether the benefits of complete revascularization — as has been shown in hemodynamically stable patients with acute MI — are seen with this approach. However, at present, there are no randomized studies comparing outcomes separately between culprit lesion-only PCI, staged multivessel PCI and single-setting multivessel PCI in patients with acute MI and cardiogenic shock,” he said.

“Second, with increasing routine use of mechanical circulatory support devices during complex interventions, it will be interesting to see whether use of such hemodynamic support devices independently affects clinical outcomes with either revascularization strategy.”

Consequently, more randomized trials and real-world or registry studies would be beneficial and help better identify the optimal management strategy in this high-risk group of patients, according to Kundu.

For now, though, the results from this meta-analysis suggest that multivessel PCI provides no additional benefit regarding short- or long-term outcomes, he noted.

“However, the optimal revascularization strategy should be decided on an individual basis after taking into account a number of factors such as age, comorbid medical conditions, the degree of hemodynamic deterioration and the complexity of underlying coronary lesions,” Kundu told Cardiology Today’s Intervention. “In clinical practice, the decision to perform complete revascularization in patients with shock is often influenced by the results of initial culprit lesion-only PCI. Interventionalists may be tempted to forego additional revascularization when significant hemodynamic improvement occurs after successful culprit lesion-only PCI. Conversely, patients with continued hemodynamic instability after culprit lesion-only PCI are more likely to undergo further multivessel PCI as a salvage procedure.” – by Melissa Foster

For more information:

Amartya Kundu, MD, can be reached at amartya.kundu@umassmemorial.org.

Disclosure: The authors report no relevant financial disclosures.