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More extensive primary percutaneous coronary intervention (PCI) may improve clinical outcomes in critically ill patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease, according to a study published online January 23, 2013, ahead of print in JACC: Cardiovascular Interventions.
For the prospective study, Darren Mylotte, MD, of Institut Hospitalier Jacques Cartier (Massy, France), and colleagues looked at 266 STEMI patients with resuscitated cardiac arrest and cardiogenic shock treated at 5 French centers between 1998 and 2010. In all, 169 (63.5%) had multivessel disease.
More Revascularization Improves Survival
Patients with single-vessel disease (36.5%) had increased 6-month survival compared with those with multivessel disease (29.6% vs. 42.3%; P = 0.032).
Of the patients with multivessel disease, 60.9% (n = 103) had culprit-only primary PCI and 39.1% (n = 66) had multivessel primary PCI. Patients who only underwent PCI in the culprit vessel had a higher incidence of initial TIMI flow grade 0 (75.7% vs. 56.1%; P = 0.011) and RCA location of the infarct-related artery (30.1% vs. 15.2%; P = 0.029).
Six-month survival (primary endpoint) was improved in patients who underwent multivessel PCI compared with culprit-only PCI (43.9% vs. 20.4%; P = 0.0017). The survival advantage was driven by a reduction in the composite of recurrent cardiac arrest and death from shock with multivessel PCI (50.0% vs. 68.0%; P = 0.024).
On multivariable analysis, successful PCI of the culprit artery (HR 0.54; 95% CI 0.34-0.85; P = 0.009) and multivessel primary PCI (HR 0.53; 95% CI 0.36-0.80; P = 0.002) were associated with decreased 6-month mortality for patients with multivessel disease.
Tailoring Treatment Still Key
“The results of this study suggest that more complete upfront revascularization has the potential to improve outcomes in these critically ill patients,” Dr. Mylotte and colleagues write.
But ultimately, they continue, “the revascularization strategy for each patient with STEMI and [cardiogenic shock] should be individualized. In patients with [multivessel disease], the hemodynamic status should be reassessed following PCI of the [infarct-related artery]. If [cardiogenic shock] persists, [multivessel] primary PCI should be considered, depending on the complexity of the nonculprit lesions and their capacity to induce myocardial ischemia.”
The study provides preliminary evidence that this strategy might improve clinical outcomes, they conclude, “supporting what is intuitively proposed by practice guidelines and practiced by physicians worldwide, and underscoring the need for adequately powered randomized trials to define the role of more complete revascularization in these critically ill patients.”
Strides in Treating ‘Sickest of the Sick’
In an accompanying editorial, Karl B. Kern, MD, of the University of Arizona (Tucson, AZ), notes that the results are “consistent with the growing database of cohort studies showing remarkable outcome improvements with more aggressive post-resuscitation care.”
Although this has been suggested previously, Dr. Kern adds, the study presents the “first clinical evidence of efficacy for this approach. Perhaps they were successful in showing such an improvement because of the very high-risk population studied.”
He praises the study authors for being “pioneers from Paris [who] have reset the bar in treating the ‘sickest of the sick’ among cardiac patients.” While Dr. Kern is hopeful that such therapy will eventually be extended to post-cardiac arrest patients in other regions, he notes “this will likely only occur when we recognize the importance of complete, emergency revascularization in this very sick subgroup of STEMI patients.”
Some Evidence Better Than None
In a telephone interview with TCTMD, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said that although the guidelines recommend multivessel PCI for patients in cardiogenic shock, “it wasn’t always easy to find the evidence. This is not very convincing, but it is a little bit of evidence.”
Even with the guidelines, Dr. Brener said, “there is a big selection bias there of who gets what” as the majority of patients in the study still received single-vessel PCI. “It’s very difficult to be sure that [you’re comparing] apples to apples,” he added. “But it’s a great attempt to try and tease this out of the group that they had and there isn’t any alternative data to suggest the contrary.”
Acknowledging the difficulty of performing a true randomized trial in this patient group, he said a prospective study could provide further clinical confirmation.
Overall, death in the catheterization lab or within 24 hours of hospital admission occurred in 7.9% and 29.3% of patients, respectively. A small proportion of patients had reinfarction (1.9%) or repeat emergent PCI (3.8%). Recurrent in-hospital cardiac arrest after primary PCI occurred in almost one-third of patients (32.7%).
2. Kern KB. ST-segment elevated myocardial infarction, cardiac arrest, and cardiogenic shock: An interventional triumvirate of opportunity. J Am Coll Cardiol Intv. 2013;Epub ahead of print.