Multi- vs culprit-vessel percutaneous coronary intervention in cardiogenic shock
Selected in JACC: Cardiovascular Interventions by M. Alasnag
This study compares outcomes of patients enrolled in the National Cardiogenic Shock Initiative (NCSI) registry treated using a strategy of MV-PCI vs CV-PCI and examines outcomes in patients treated with early MCS.
References
Authors
Lemor A, Basir MB, Patel K, Kolski B, Kaki A, Kapur N, Riley R, Finley J, Goldsweig A, Aronow HD, Belford PM, Tehrani B, Truesdell AG, Lasorda D, Bharadwaj A, Hanson I, LaLonde T, Gorgis S, O’Neill W on behalf of the National Cardiogenic Shock Initiative Investigators.
Reference
JACC: Cardiovascular Interventions. DOI: 10.1016/j.jcin.2020.03.012
Published
29 April 2020
Link
Read the abstractReviewer
My Comment
Why this study? – the rationale/objective
The COMPLETE Study published in 2019 concluded that complete revascularisation (culprit and non-culprit) in the setting of an acute myocardial infarction (AMI) improved hard cardiovascular outcomes including cardiovascular death, myocardial infarction and ischemia driven revascularisation. The study, however, represented a low-risk cohort. The CULPRIT SHOCK Study evaluating those with AMI and cardiogenic shock concluded that the risk of death or renal-replacement therapy was lower with culprit-vessel only (CV-PCI) compared to multivessel revascularisation (MV-PCI) at thirty day follow up. In 2018, the one-year results were published. The study demonstrated no significant difference in mortality between the two groups at one year follow up. Furthermore, the complete arm had a higher rate of repeat revascularisation and hospitalization for heart failure at one year.
In this study, Lemor et al compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) registry treated using a strategy of MV-PCI versus CV-PCI. The study also examined outcomes in patients treated with early mechanical circulatory support (MCS).
Of note, the NCSI is an algorithm adopted by 57 centers in the USA for the treatment of AMI and shock. It includes early identification and catheterization laboratory activation, early use of MCS and routine use of invasive hemodynamic monitoring with pulmonary artery catheters to guide management.
How was it executed? – the methodology
Patients with AMI and shock presenting to an NCSI center from July 2016 to December 2019 and multivessel disease were enrolled. All patients were treated using a standard shock protocol with early MCS, revascularisation, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were categorized into those receiving CV-PCI or MV-PCI during the index procedure. The primary outcome was hospital survival. Secondary outcomes included length of hospital stay and rates of acute kidney injury (AKI) (defined as an increase in creatinine of 1.5 times from baseline and excluded those with end-stage renal disease).
What is the main result?
A total of 198 patients with MVCAD were enrolled. MV-PCI was used in 126 (64%) and CV-PCI in 72 (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction (MI). The mean age was 64 years and men comprised approximately 80% of the total cohort. An ejection fraction < 50% was seen in 24 % MV-PCI and 28% CV-PCI of the cohort. Cardiogenic shock was noted in 66 and 71% on admission. Using the SCAI definitions, Classical shock was noted in 56 and 58% and Extremis in 28 and 37%. Out of hospital arrest was also noted in 44% in both arms. Cardiopulmonary resuscitation was performed in 7 and 11% at the time of insertion of MCS (namely Impella). Overall, Impella was inserted pre-PCI in 70 and 72%, during the PCI in 20 and 22%, and post PCI in 7 and 8% of the cases.
Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation. Cardiac performance was significantly worse at 12 hours. After the first 24 hours, the hemometabolic derangements were similar. Surviving the hospital stay and rates of acute kidney injury were not significantly different between the groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively).
The median hospital stay was10 (range: 5 to 16) days for those undergoing MV-PCI and 8 (range: 4 to 14) days for patients with CV-PCI. When stratified according to the number of coronary arteries, those with 3-vessel CAD who had undergone MV-PCI, the survival was 65.7% if they had 2-vessel PCI and 72.7% if they had 3-vessel PCI.
Critical reading and the relevance for clinical practice
Using standardized definitions and management protocols for shock are the cornerstone of the NCSI initiative. This study illustrates that early MCS and revascularisation of non-culprit lesions were associated with similar hospital survival rates and AKI when compared to culprit-only PCI. Performing complete revascularsation while the MCS is still in place is conceivable with no additional penalty. It is important at this junction to determine what the treatment endpoints for shocked patients are. Will elaborate revascularisation including chronic total occlusions add a survival benefit? Based on data from the Culprit Shock which was a larger randomized study, it does not have a survival advantage. The outcomes reported are shortsighted (surviving hospitalization). It is important to note, however, the profile of patients enrolled is very high risk with advanced shock (Extremis) and even out of hospital arrest included in the analysis. With such presentations, surviving hospital discharge can be considered a victory. Since the data is observational, single-arm and only includes NCSI centers, it cannot be assumed that the results are reproducible worldwide.
Routine use of MCS has always been controversial. At this point, it is important to discuss another randomized trial published this week (Azzalini L, Johal GS, Baber U, et al. Outcomes of Impella-supported high-risk non-emergent percutaneous coronary intervention in a large single-center registry [published online ahead of print, 2020 Apr 25]. Catheter Cardiovasc Interv. 2020;10.1002/ccd.28931). This study compared non-emergent PCI with MCS, Impella, to PCI without MCS (250 in each arm). Similar to the PROTECT Trials, the MCS arm had a higher rate of Left main interventions (26% vs 11%) and rotablation (44% vs 37%). Consequently, the MCS arm had a higher rate of periprocedural myocardial infarctions (14.0% vs 6.4%), major drop in blood (6.8% vs 2.8%) and blood transfusion (11.2% vs 4.8%). Ultimately, balancing risk and benefits of preemptive MCS use in non-emergent interventions is imperative.
In the setting of shock, streamlining protocols for the use of MCS is equally important. Longterm data generated by the NCSI initiative are much anticipated. At this time, both the CULPRIT SHOCK trial and data from this NCSI study do NOT recommend universal complete revascularisation.
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