Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?

Reperfusion in Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times

BACKGROUND

In patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the preferred revascularization option. Little is known about the efficacy and safety of a pharmacoinvasive approach for patients with cardiogenic shock presenting to a non-PCI hospital with prolonged interhospital transport times.

METHODS

In a retrospective analysis of geographically extensive ST-segment-elevation myocardial infarction network (2006-2021), 426 patients with cardiogenic shock and ST-segment-elevation myocardial infarction presented to a non-PCI-capable hospital and underwent reperfusion therapy (53.8% pharmacoinvasive and 46.2% pPCI). The primary clinical outcome was a composite of in-hospital mortality, renal failure requiring dialysis, cardiac arrest, or mechanical circulatory support, and the primary safety outcome was major bleeding defined as an intracranial hemorrhage or bleeding that required transfusion was compared in an inverse probability weighted model. The electrocardiographic reperfusion outcome of interest was the worst residual ST-segment-elevation.

RESULTS

Patients with pharmacoinvasive treatment had longer median interhospital transport (3 hours versus 1 hour) and shorter median symptom-onset-to-reperfusion (125 minute-to-needle versus 419 minute-to-balloon) times. ST-segment resolution ≥50% on the postfibrinolysis ECG was 56.6%. Postcatheterization, worst lead residual ST-segment-elevation <1 mm (57.3% versus 46.3%; P=0.01) was higher in the pharmacoinvasive compared with the pPCI cohort, but no differences were observed in the worst lead ST-segment-elevation resolution ≥50% (77.4% versus 81.8%; P=0.57). The primary clinical end point was lower in the pharmacoinvasive cohort (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26-0.72]; P<0.01) compared with patients who received pPCI. An interaction between interhospital transfer time and reperfusion strategy with all-cause mortality was observed, favoring a pharmacoinvasive approach with transfer times >60 minutes. The incidence of the primary safety outcome was 10.1% in the pharmacoinvasive arm versus 18.7% in pPCI (adjusted odds ratio, 0.41 [95% CI, 0.14-1.09]; P=0.08).

CONCLUSIONS

In patients with ST-segment-elevation myocardial infarction presenting with cardiogenic shock and prolonged interhospital transport times, a pharmacoinvasive approach was associated with improved electrocardiographic reperfusion and a lower rate of death, dialysis, or mechanical circulatory support without an increase in major bleeding.

The Impact of Sex on Cardiogenic Shock Outcomes Following ST Elevation Myocardial Infarction

BACKGROUND

Cardiogenic shock (CS) remains the leading cause of ST elevation myocardial infarction (STEMI)-related mortality. Contemporary studies have shown no sex-related differences in mortality.

METHODS

STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) were included based on a dedicated prospective STEMI database. We compared sex-specific differences in CS characteristics at baseline, during hospitalization, and in subsequent clinical outcomes. Endpoints included all-cause mortality and major adverse cardiac events (MACE).

RESULTS

Of 3202 consecutive STEMI patients, 210 (6.5%) had CS, of which 63 (30.0%) were women. Women were older than men (73.2 vs. 65.5% y, p < 0.01), and more had hypertension (68.3 vs. 52.8%, p = 0.019) and diabetes (38.7 vs. 24.8%, p = 0.047). Fewer were smokers (13.3 vs. 41.2%, p < 0.01), had previous PCI (9.1 vs. 22.3% p = 0.016), or required IABP (35.3 vs. 51.1% p = 0.027). Women had higher rates of mortality (53.2 vs. 35.3% in-hospital, p = 0.01; 61.3 vs. 41.9% at 1 month, p = 0.01; and 73.8 vs. 52.6% at 3 years, p = 0.05) and MACE (60.6 vs. 41.6% in-hospital, p = 0.032; 66.1 vs. 45.6% at 1 month, p = 0.007; and 62.9 vs. 80.3% at 3 years, p = 0.015). After multivariate adjustment, female sex remained an independent factor for death (HR-2.42 [95% CI 1.014-5.033], p = 0.042) and MACE (HR-1.91 [95% CI 1.217-3.031], p = 0.01).

CONCLUSIONS

CS complicating STEMI is associated with greater short- and long-term mortality and MACE in women. Sex-focused measures to improve diagnosis and treatment are mandatory for CS patients.

Outcomes After Left Main Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock (from the German ALKK PCI Registry)

Early revascularization therapy with percutaneous coronary intervention (PCI) has been shown to improve outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Data from consecutive patients with AMI and CS treated with PCI enrolled into the prospective Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte-PCI registry were centrally collected and analyzed. Patients were divided into 4 groups with PCI for left main (LM), 1-vessel, 2-vessel, and 3-vessel diseases. Patients' characteristics, procedural features, antithrombotic therapies, and in-hospital complications were compared between the 4 groups. Between 2010 and 2015 a total of 2,348 consecutive patients with AMI and CS were treated by PCI in 51 hospitals, 295 for LM (15 for protected, 280 for unprotected) and single-vessel (n = 491), 2-vessel (n = 524), and 3-vessel disease (n = 1,038). Thrombolysis in myocardial infarction 3 patency of the culprit lesion after PCI was 84.3%, 84.0%, 80.8%, and 84.6% in single-vessel, 2-vessel, 3-vessel disease, and LM PCI, respectively, whereas in-hospital mortality was 27.9%, 33.9%, 46.5%, and 55.9%. Bleeding rates were low (2.0%-2.3 %) and not different between groups. In a multivariate analysis a higher age, thrombolysis in myocardial infarction flow <3 after PCI, 3-vessel disease, and LM PCI were independent predictors of mortality. In conclusion, PCI of the LM is performed in about 12.5% of patients with AMI and CS and was associated with a high procedural success rate, whereas mortality is increased with LM PCI.

Incidence and outcomes of cardiogenic shock among women with spontaneous coronary artery dissection

BACKGROUND

There is a paucity of data on cardiogenic shock (CS) incidence and outcomes among patients with spontaneous coronary artery dissection (SCAD).

METHODS

Women admitted to the hospital for acute myocardial infarction (AMI) with and without SCAD were identified from the United States National Readmission Database from October 1, 2015 to December 31, 2018. We calculated the incidence of CS among women with AMI with and without SCAD and odds for developing CS after adjusting for baseline characteristics. In addition, we report the utilization of percutaneous coronary intervention, mechanical circulatory support, severe disability surrogates, and 30-day readmission rates.

RESULTS

A total of 664,292 patients admitted for AMI were eligible for analysis, including 6643 patients with SCAD and 657,649 without SCAD. Patients with SCAD were younger (57 years [interquartile range, IQR 48-68] vs. 71 years [IQR 60-81], p < 0.01) and had fewer comorbidities yet had a higher incidence of CS as compared to patients without SCAD (9% vs. 5%, p < 0.01) and remained at elevated risk after adjusting for baseline comorbidities (adjusted odds ratio 1.5 [95% confidence interval, CI 1.2-1.7]). Among patients who developed CS, those with SCAD had lower in-hospital mortality than non-SCAD (31% vs. 39%, p < 0.01), and were more likely to receive mechanical circulatory support.

CONCLUSIONS

In a nationally representative sample of women admitted for AMI, we found that patients with SCAD had a higher risk of developing CS and required more frequent use of mechanical circulatory support but were more likely to survive to discharge than women suffering AMI from causes other than SCAD.

Multivessel vs. Culprit Vessel-Only Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction in Patients With Cardiogenic Shock: An Updated Systematic Review and Meta-Analysis

Background

The optimal revascularization strategy in patients with ST-segment elevation myocardial infarction (STEMI) complicating by cardiogenic shock (CS) remains controversial. This study aims to evaluate the clinical outcomes of multivessel percutaneous coronary intervention (MV-PCI) compared to culprit vessel-only PCI (CO-PCI) for the treatment, only in patients with STEMI with CS.

Methods

A comprehensive literature search was conducted. Studies assessed the efficacy outcomes of short (in-hospital or 30 days)/long-term mortality, cardiac death, myocardial reinfarction, repeat revascularization, and safety outcomes of stroke, bleeding, acute renal failure with MV-PCI vs. CO-PCI in patients with STEMI with CS were included. The publication bias and sensitivity analysis were also performed.

Results

A total of 15 studies were included in this meta-analysis. There was no significant difference in short- and long-term mortality in patients treated with MV-PCI compared to CO-PCI group [odds ratio (OR) = 1.17; 95% confidence interval (CI), 0.92–1.48; OR = 0.86; 95% CI, 0.58–1.28]. Similarly, there were no significant differences in cardiac death (OR = 0.67; 95% CI, 0.44–1.00), myocardial reinfarction (OR = 1.24; 95% CI, 0.77–2.00), repeat revascularization (OR = 0.75; 95% CI, 0.40–1.42), bleeding (OR = 1.53; 95% CI, 0.53–4.43), or stroke (OR = 1.42; 95% CI, 0.90–2.23) between the two groups. There was a higher risk in acute renal failure (OR = 1.33; 95% CI, 1.04–1.69) in patients treated with MV-PCI when compared with CO-PCI.

Conclusion

This meta-analysis suggests that there may be no significant benefit for patients with STEMI complicating CS treated with MV-PCI compared with CO-PCI, and patients are at increased risk of developing acute renal failure after MV-PCI intervention.

Cardiogenic Shock After Acute Myocardial Infarction: A Review

IMPORTANCE

Cardiogenic shock affects between 40 000 and 50 000 people in the US per year and is the leading cause of in-hospital mortality following acute myocardial infarction.

OBSERVATIONS

Thirty-day mortality for patients with cardiogenic shock due to myocardial infarction is approximately 40%, and 1-year mortality approaches 50%. Immediate revascularization of the infarct-related coronary artery remains the only treatment for cardiogenic shock associated with acute myocardial infarction supported by randomized clinical trials. The Percutaneous Coronary Intervention Strategies with Acute Myocardial Infarction and Cardiogenic Shock (CULPRIT-SHOCK) clinical trial demonstrated a reduction in the primary outcome of 30-day death or kidney replacement therapy; 158 of 344 patients (45.9%) in the culprit lesion revascularization-only group compared with 189 of 341 patients (55.4%) in the multivessel percutaneous coronary intervention group (relative risk, 0.83 [95% CI, 0.71-0.96]; P = .01). Despite a lack of randomized trials demonstrating benefit, percutaneous mechanical circulatory support devices are frequently used to manage cardiogenic shock following acute myocardial infarction.

CONCLUSIONS AND RELEVANCE

Cardiogenic shock occurs in up to 10% of patients immediately following acute myocardial infarction and is associated with mortality rates of nearly 40% at 30 days and 50% at 1 year. Current evidence and clinical practice guidelines support immediate revascularization of the infarct-related coronary artery as the primary therapy for cardiogenic shock following acute myocardial infarction.

Culprit lesion location and outcomes in patients with multivessel disease and infarct-related cardiogenic shock: a core laboratory analysis of the CULPRIT-SHOCK trial

BACKGROUND

Critical culprit lesion locations (CCLL) such as left main (LM) and proximal left anterior descending (LAD) are associated with worse clinical outcome in myocardial infarction without cardiogenic shock (CS).

AIMS

We aimed to assess whether CCLL identify a subgroup of patients with poorer prognosis when presenting with CS.

METHODS

In the CULPRIT-SHOCK trial, a core laboratory reviewed all coronary angiograms to identify CCLL. A CCLL was defined as a culprit lesion with a >70% diameter stenosis of the LM, LM equivalent (>70% diameter stenosis of both proximal LAD and proximal circumflex), proximal LAD or last remaining vessel. We evaluated the primary study endpoint of the CULPRIT-SHOCK trial according to CCLL.

RESULTS

A total of 269 (43%) out of 626 patients eligible for this analysis had a CCLL. Death or renal replacement therapy within 30 days, death within 30 days and death within one year were significantly higher in the CCLL than in the non-CCLL group (58.4% vs 43.4%, p<0.001, 55.8% vs 39.5%, p<0.001, 61.0% vs 44.5%, p<0.001, respectively). This was consistent after adjustment for baseline and angiographic characteristics. No interaction with the randomisation group (culprit lesion-only or immediate multivessel PCI) was found.

CONCLUSIONS

CCLL is frequent in CS and independently associated with worse clinical outcomes irrespective of the revascularisation strategy.

TRIAL REGISTRATION

www.clinicaltrials.gov NCT01927549.

Multivessel Intervention in Myocardial Infarction with Cardiogenic Shock: CULPRIT-SHOCK Trial Outcomes in the PL-ACS Registry

Background: The aim of the study was a comparison of culprit-lesion-only (CL-PCI) with the multivessel percutaneous coronary intervention (MV-PCI) in terms of 30-day and 12-month mortality in a national registry. Methods: Patients from the PL-ACS registry with MI and CS were analyzed. Patients meeting the criteria of the CULPRIT-SHOCK trial were divided into two groups: CL-PCI and MV-PCI groups. Results: Of the 3265 patients in the PL-ACS registry with MI complicated by CS, the criteria of the CULPRIT-SHOCK trial were met by 2084 patients (63.8%). The CL-PCI was performed in 883 patients, and MV-PCI was performed in 1045 patients. After the propensity score matching analysis, 617 well-matched pairs were obtained. In a 30-day follow-up, death from any cause occurred in 49.3% in the CL-PCI group and 57.0% in the MV-PCI group (RR 0.86, 95% CI 0.58–0.92, p = 0.0081). After 12 months, the rate of mortality was 62.5% in the CL-PCI group and 68.0% in the MV-PCI group (RR 0.92, 95% CI 0.84–1.01, p = 0.066). Conclusions: The results confirm the validity of CULPRIT-SHOCK findings in a national registry and current guideline-recommended strategy of revascularization limited to the infarct-related artery.

Prognostic importance of culprit lesion location in cardiogenic shock due to myocardial infarction

BACKGROUND

As existing results are diverging, and the patient population has changed significantly, this study sought to investigate the prognostic importance of the culprit lesion location in patients with cardiogenic shock due to myocardial infarction (AMICS), in a contemporary and unselected patient population.

METHODS

From the recruitment area of two tertiary heart centres in Denmark, covering 3.9 million citizens corresponding to two-thirds of the Danish population, all AMICS patients in the period of 2010-2017 were individually identified and validated through patient records.

RESULTS

A total of 1716 patients with AMICS were identified. Immediate revascularization was performed in 1482 patients (86%). Among these, a culprit lesion in the left main coronary artery (LM) was associated with the highest 30-day mortality rate (66%), plogrank<0.0001, which persisted after multivariable adjustment for variables known to be associated with mortality in AMICS, including age, gender, heart rate, lactate, diabetes, stroke and out-of-hospital cardiac arrest, p=0.002. A culprit lesion in the remaining coronary arteries had comparable and lower 30-day mortality (43-48%), plogrank=0.39. Patients with multivessel disease had comparable prognoses irrespective of whether a culprit-only or multivessel percutaneous coronary intervention strategy was used (plogrank=0.80), and whether partial or complete revascularization was achieved (plogrank=0.24).

CONCLUSIONS

Among AMICS patients undergoing revascularization, a LM culprit lesion was associated with the highest short-term mortality, whereas patients with a culprit lesion in the remaining coronary arteries had comparable and lower mortality rates. Multivessel disease patients had similar prognoses irrespective of percutaneous coronary intervention approach and whether partial or complete revascularization was achieved.

Sex Differences in Outcomes After Myocardial Infarction in the Community

PURPOSE

Prior studies observed that women experienced worse outcomes than men after myocardial infarction but did not convincingly establish an independent effect of female sex on outcomes, thus failing to impact clinical practice. Current data remain sparse and information on long-term nonfatal outcomes is lacking. To address these gaps in knowledge, we examined outcomes after incident myocardial infarction for women compared with men.

METHODS

We studied a population-based myocardial infarction incidence cohort in Olmsted County, Minnesota, between 2000 and 2012. Patients were followed for recurrent myocardial infarction, heart failure, and death. A propensity score was constructed to balance the clinical characteristics between men and women; Cox models were weighted using inverse probabilities of the propensity scores.

RESULTS

Among 1959 patients with incident myocardial infarction (39% women; mean age 73.8 and 64.2 for women and men, respectively), 347 recurrent myocardial infarctions, 464 heart failure episodes, 836 deaths, and 367 cardiovascular deaths occurred over a mean follow-up of 6.5 years. Women experienced a higher occurrence of each adverse event (all P <0.01). After propensity score weighting, women had a 28% increased risk of recurrent myocardial infarction (hazard ratio: 1.28, 95% confidence interval: 1.03-1.59), and there was no difference in risk for any other outcomes (all P >0.05).

CONCLUSION

After myocardial infarction, women experience a large excess risk of recurrent myocardial infarction but not of heart failure or death independently of clinical characteristics. Future studies are needed to understand the mechanisms driving this association.

Economic evaluation of culprit lesion only PCI vs. immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: the CULPRIT-SHOCK trial

BACKGROUND

The CULPRIT-SHOCK trial compared two treatment strategies for patients with acute myocardial infarction and multivessel coronary artery disease complicated by cardiogenic shock: (a) culprit vessel only percutaneous coronary intervention (CO-PCI), with additional staged revascularisation if indicated, and (b) immediate multivessel PCI (MV-PCI).

METHODS

A German societal and national health service perspective was considered for three different analyses. The cost utility analysis (CUA) estimated costs and quality adjusted life years (QALYs) based on a pre-trial decision analytic model taking a lifelong time horizon. In addition, a within trial CUA estimated QALYs and costs for 1 year. Finally, the cost effectiveness analysis (CEA) used the composite primary outcome, mortality and renal failure at 30-day follow-up, and the within trial costs. Econometric and survival analysis on the trial data was used for the estimation of the model parameters. Subgroup analysis was performed following an economic protocol.

RESULTS

The lifelong CUA showed an incremental cost effectiveness ratio (ICER), CO-PCI vs. MV-PCI, of €7010 per QALY and a probability of CO-PCI being the most cost-effective strategy > 64% at a €30,000 threshold. The ICER for the within trial CUA was €14,600 and the incremental cost per case of death/renal failure avoided at 30-day follow-up was €9010. Cost-effectiveness improved with patient age and for those without diabetes.

CONCLUSIONS

The estimates of cost-effectiveness for CO-PCI vs. MV-PCI have been shown to change depending on the time horizon and type of economic evaluation performed. The results favoured a long-term horizon analysis for avoiding underestimation of QALY gains from the CO-PCI arm.

Prognostic impact of angiographic findings, procedural success, and timing of percutaneous coronary intervention in cardiogenic shock

Aims

Urgent revascularization is the mainstay of treatment in acute coronary syndrome (ACS) related cardiogenic shock (CS). The aim was to investigate the association of angiographic results with 90‐day mortality. Procedural complications of percutaneous coronary intervention (PCI) were also examined.

Methods and results

This CardShock (NCT01374867) substudy included 158 patients with ACS aetiology and data on coronary angiography and complications during PCI procedure. Survival analysis was conducted with Kaplan–Meier curves and Cox regression analysis. Median age was 67 ± 11 years, and 77% were men. During 90‐day follow‐up, 66 (42%) patients died. Patients with one‐vessel disease (n = 49) had lower mortality than patients with two‐vessel (n = 59) or three‐vessel (n = 50) disease (25% vs. 48% vs. 52%, P = 0.011). Successful revascularization [Thrombolysis in Myocardial Infarction (TIMI) Flow 3 post‐PCI) was achieved more often in survivors than non‐survivors (81% vs. 60%, P = 0.019). The median symptom‐to‐balloon time was 340 (196–660) minutes, with no difference between survivors and non‐survivors. In multivariable mortality analysis, multivessel disease (HR 2.59, CI_95% 1.29–5.18) and TIMI flow <3 post‐PCI (HR 2.41, CI_95% 1.4–4.15) were associated with 90‐day mortality. Procedural PCI complications were recorded in 51 (35%) patients, arrhythmic complications being the most common (n = 32, 63%). The incidence of complications was similar between survivors and non‐survivors (31% vs. 42%, P = 0.21).

Conclusions

Multivessel disease is associated with worse survival in ACS‐related CS. In patients undergoing PCI, arrhythmic complications were common, but not associated with excess mortality. Successful revascularization of the IRA had positive effect on outcome despite delay from symptom onset.

How to Bail Out Patients with Severe Acute Myocardial Infarction

Cardiogenic shock (CS) is the most serious complication of acute myocardial infarction (AMI). The practice of early revascularization by percutaneous coronary intervention, and advances in pharmacotherapy have reduced the rate of complications of CS. However, when CS is combined with AMI, mortality from AMI is still high, and many clinicians are wondering how to treat CS with AMI. In recent years, mechanical circulatory support (MCS) devices have improved the clinical outcome in AMI patients with CS. For best outcome, treatment of AMI with CS should always consider treatments that improve the prognosis of the patients.

In-hospital outcome in patients presenting with acute coronary syndrome with left main coronary artery disease: A report from Japanese prospective multicenter percutaneous coronary intervention registry

BACKGROUND

Patients presenting with acute coronary syndrome (ACS) from left main (LM) disease are at a high risk for mortality despite recent advancement in devices and techniques during percutaneous coronary interventions (PCI). We aimed to evaluate patient characteristics, clinical presentations, and key clinical characteristics associated with adverse in-hospital outcomes among ACS patients undergoing LM-PCI.

METHODS

We retrospectively identified 280 LM-ACS patients (3.7 %) from 7608 ACS patients in the prospective multicenter Japan Cardiovascular Database-Keio Inter-Hospital Cardiovascular Studies registry from March 2009 to May 2016 and divided them into those with/without PCI/coronary artery bypass grafting. We compared baseline demographics, coronary lesion characteristics, PCI details, and short-term outcomes, including in-hospital mortality and periprocedural complications, between the two groups.

RESULTS

Among LM-ACS patients, 38.6 % presented with ST elevation myocardial infarction, 29.6 % with cardiogenic shock (CS), and 15.4 % with cardiac arrest. The observed in-hospital mortality rate was 18.9 % with presence of CS [odds ratio (OR): 10.16, 95 % confidence interval (CI): 4.51-22.91, p<0.001] and absence of prior revascularization (de novo patients; OR: 4.31, 95 % CI: 1.43-12.94, p=0.009) was independently associated with higher incidence of in-hospital mortality. Notably, the observed mortality rate was substantially higher among de novo patients than the predicted mortality rate with a contemporary risk model (observed: 25.1 %; predicted: 11.6 %).

CONCLUSIONS

Prior revascularization act as a protective factor among LM-ACS patients in the contemporary era of PCI. Further studies to detect those at higher risk for LM coronary lesion progression are needed to fully implement these findings into clinical practice.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion

BACKGROUND

Identification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression.

METHODS

STEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression.

RESULTS

Emergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001).

CONCLUSIONS

STE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

Predictors of Outcomes in Myocardial Infarction and Cardiogenic Shock

Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.

One-Year Outcomes after PCI Strategies in Cardiogenic Shock

BACKGROUND

Among patients with acute myocardial infarction, cardiogenic shock, and multivessel coronary artery disease, the risk of a composite of death from any cause or severe renal failure leading to renal-replacement therapy at 30 days was found to be lower with percutaneous coronary intervention (PCI) of the culprit lesion only than with immediate multivessel PCI. We evaluated clinical outcomes at 1 year.

METHODS

We randomly assigned 706 patients to either culprit-lesion-only PCI or immediate multivessel PCI. The results for the primary end point of death or renal-replacement therapy at 30 days have been reported previously. Prespecified secondary end points at 1 year included death from any cause, recurrent myocardial infarction, repeat revascularization, rehospitalization for congestive heart failure, the composite of death or recurrent infarction, and the composite of death, recurrent infarction, or rehospitalization for heart failure.

RESULTS

As reported previously, at 30 days, the primary end point had occurred in 45.9% of the patients in the culprit-lesion-only PCI group and in 55.4% in the multivessel PCI group (P=0.01). At 1 year, death had occurred in 172 of 344 patients (50.0%) in the culprit-lesion-only PCI group and in 194 of 341 patients (56.9%) in the multivessel PCI group (relative risk, 0.88; 95% confidence interval [CI], 0.76 to 1.01). The rate of recurrent infarction was 1.7% with culprit-lesion-only PCI and 2.1% with multivessel PCI (relative risk, 0.85; 95% CI, 0.29 to 2.50), and the rate of a composite of death or recurrent infarction was 50.9% and 58.4%, respectively (relative risk, 0.87; 95% CI, 0.76 to 1.00). Repeat revascularization occurred more frequently with culprit-lesion-only PCI than with multivessel PCI (in 32.3% of the patients vs. 9.4%; relative risk, 3.44; 95% CI, 2.39 to 4.95), as did rehospitalization for heart failure (5.2% vs. 1.2%; relative risk, 4.46; 95% CI, 1.53 to 13.04).

CONCLUSIONS

Among patients with acute myocardial infarction and cardiogenic shock, the risk of death or renal-replacement therapy at 30 days was lower with culprit-lesion-only PCI than with immediate multivessel PCI, and mortality did not differ significantly between the two groups at 1 year of follow-up. (Funded by the European Union Seventh Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).

Predictive value of the baseline electrocardiogram ST-segment pattern in cardiogenic shock: Results from the CardShock Study

BACKGROUND

The most common aetiology of cardiogenic shock (CS) is acute coronary syndrome (ACS), but even up to 20%-50% of CS is caused by other disorders. ST-segment deviations in the electrocardiogram (ECG) have been investigated in patients with ACS-related CS, but not in those with other CS aetiologies. We set out to explore the prevalence of different ST-segment patterns and their associations with the CS aetiology, clinical findings and 90-day mortality.

METHODS

We analysed the baseline ECG of 196 patients who were included in a multinational prospective study of CS. The patients were divided into 3 groups: (a) ST-segment elevation (STE). (b) ST-segment depression (STDEP). (c) No ST-segment deviation or ST-segment impossible to analyse (NSTD). A subgroup analysis of the ACS patients was conducted.

RESULTS

ST-segment deviations were present in 80% of the patients: 52% had STE and 29% had STDEP. STE was associated with the ACS aetiology, but one-fourth of the STDEP patients had aetiology other than ACS. The overall 90-day mortality was 41%: in STE 47%, STDEP 36% and NSTD 33%. In the multivariate mortality analysis, only STE predicted mortality (HR 1.74, CI₉₅ 1.07-2.84). In the ACS subgroup, the patients were equally effectively revascularized, and no differences in the survival were noted between the study groups.

CONCLUSION

ST-segment elevation is associated with the ACS aetiology and high mortality in the unselected CS population. If STE is not present, other aetiologies must be considered. When effectively revascularized, the prognosis is similar regardless of the ST-segment pattern in ACS-related CS.

[Infarct-related cardiogenic shock : Prognosis and treatment]

Patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) experience cardiogenic shock in about 6-10% of cases during the hospital treatment. In recent years, the incidence seems to be decreasing due to invasive diagnostics and therapy after myocardial infarction. Early diagnosis is important to initiate immediate revascularization using percutaneous coronary intervention (PCI) with stent implantation as part of cardiogenic shock treatment. Thus, a significant improvement in survival can be achieved. Pharmacological and mechanical support is needed to maintain perfusion of the myocardium and organs. Drug therapy for infarct cardiogenic shock relies on dobutamine for inotropic agent and norepinephrine as a vasopressor. For further inotropic support, data on additional levosimendan treatment are available. The pharmacological therapy is supplemented by mechanical support systems such as Impella (ABIOMED, Danvers, MA, USA) or extracorporeal membrane oxygenation (ECMO). The intra-aortic balloon pump (IABP) is hardly used anymore. The majority of cardiogenic shock survivors have little functional cardiac impairment in the long term. This shows the transient damage component (stunning, inflammation), which underlines the need for a fast and effective cardiovascular supportive therapy.

PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock

BACKGROUND

In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial.

METHODS

In this multicenter trial, we randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke.

RESULTS

At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P=0.01). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P=0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P=0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ significantly between the two groups.

CONCLUSIONS

Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI. (Funded by the European Union 7th Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).

In-hospital mortality after acute STEMI in patients undergoing primary PCI

BACKGROUND

Acute myocardial infarction (AMI) is the main cause of global and in-hospital mortality in patients with cardiovascular diseases. We aimed to examine the association between the coronary artery involved and the in-hospital mortality in patients who underwent primary percutaneous coronary intervention (pPCI) after ST segment elevation myocardial infarction (STEMI).

METHODS

The in-hospital mortality of STEMI patients who underwent pPCI was assessed at the Department of Cardiology, Harzklinik Goslar, Germany, which has no access to immediate mechanical circulatory support (MCS), between 2013 and 2017.

RESULTS

We enrolled 312 STEMI patients, with a mean age of 67.1 ± 13.4 years, of whom 211 (68%) were male. In-hospital mortality was documented in 31 patients (10%). In-hospital mortality was associated with pre-hospital cardiopulmonary resuscitation (CPR; n = 39/12.5%), older age, lower systolic blood pressure, Killip class > 1, triple-vessel disease (each p < 0.0001), female gender (p = 0.0158), and with the localization of the treated culprit lesion in the left main coronary artery (LMCA; p = 0.0083) and in the ramus circumflexus (RCX; p = 0.0141).

CONCLUSION

In this monocentric cohort, all-cause in-hospital mortality of STEMI patients after pPCI was significantly higher in those patients with culprit lesions in the LMCA and in the RCX, which may prove to be a substantial novel risk factor for STEMI-related mortality. Increasing age and female gender may be interdependent risk factors for mortality in this patient population. Furthermore, our data highlight the importance of the availability of MCS options in pPCI centers for patients after CPR.

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.

Multivessel versus culprit lesion only percutaneous revascularization plus potential staged revascularization in patients with acute myocardial infarction complicated by cardiogenic shock: Design and rationale of CULPRIT-SHOCK trial

BACKGROUND

In acute myocardial infarction complicated by cardiogenic shock (CS), up to 80% of patients present with multivessel coronary artery disease. Currently, the best revascularization strategy is unknown. Therefore, a prospective randomized adequately powered clinical trial is warranted.

STUDY DESIGN

The CULPRIT-SHOCK study is a 706-patient controlled, international, multicenter, randomized, open-label trial. It is designed to compare culprit lesion only percutaneous coronary intervention (PCI) with possible staged non-culprit lesion revascularization versus immediate multivessel PCI in patients with CS complicating acute myocardial infarction. Patients will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoint of CULPRIT-SHOCK is 30-day mortality and severe renal failure requiring renal replacement therapy. Secondary outcome measures such as hemodynamic, laboratory, and clinical parameters will serve as surrogate endpoints for prognosis. Furthermore, an intermediate- and long-term follow-up at 6 and 12 months will be performed. Safety endpoints include the assessment of bleeding and stroke.

CONCLUSIONS

The CULPRIT-SHOCK trial will address the question of optimal revascularization strategy in patients with multivessel disease and acute myocardial infarction complicated by CS.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Outcomes in patients with cardiogenic shock following percutaneous coronary intervention in the contemporary era: an analysis from the BCIS database (British Cardiovascular Intervention Society)

OBJECTIVES

This study sought to determine mortality rates among cardiogenic shock (CGS) patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome in the contemporary treatment era and to determine predictors of mortality.

BACKGROUND

It is unclear whether recent advances in pharmacological and interventional strategies have resulted in further improvements in short- and long-term mortality and which factors are associated with adverse outcomes in patients presenting with CGS and undergoing PCI in the setting of acute coronary syndrome.

METHODS

This study analyzed prospectively collected data for patients undergoing PCI in the setting of CGS as recorded in the BCIS (British Cardiovascular Intervention Society) PCI database.

RESULTS

In England and Wales, 6,489 patients underwent PCI for acute coronary syndrome in the setting of CGS. The mortality rates at 30 days, 90 days, and 1 year were 37.3%, 40.0%, and 44.3%, respectively. On multiple logistic regression analysis, age (for each 10-year increment of age: odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.51 to 1.68; p < 0.0001), diabetes mellitus (OR: 1.47, 95% CI: 1.28 to 1.70; p < 0.0001), history of renal disease (OR: 2.03, 95% CI: 1.63 to 2.53; p < 0.0001), need for artificial mechanical ventilation (OR: 2.56, 95% CI: 2.23 to 2.94; p < 0.0001), intra-aortic balloon pump use (OR: 1.57, 95% CI: 1.40 to 1.76; p < 0.0001), and need for left main stem PCI (OR: 1.90, 95% CI: 1.62 to 2.23; p < 0.0001) were associated with higher mortality at 1 year.

CONCLUSIONS

In this large U.K. cohort of patients undergoing PCI in the context of CGS, mortality remains high in spite of the use of contemporary PCI strategies. The highest mortality occurs early, and this time period may be a particular target of therapeutic intervention.

Evolving strategies in the treatment of acute myocardial infarction-induced cardiogenic shock

Despite advances in medical technology and re-vascularization interventions, the mortality rate for cardiogenic shock (CS) following acute myocardial infarction has remained at 50%. The majority of these mortalities are from left ventricular failure resulting in multi-system organ dysfunction. The field of mechanical circulatory support (MCS) has evolved within the past decade, with improved outcomes from extracorporeal membrane oxygenation as well as continuous-flow left ventricular assist devices (CF LVADs). In this paper, we discuss our institutional treatment strategies, the rationale for the protocol development, and our improved outcomes when using MCS in patients with refractory CS following acute myocardial infarction.

Deadly association of cardiogenic shock and chronic total occlusion in acute ST-elevation myocardial infarction

BACKGROUND

The association between cardiogenic shock and 1 or >1 chronic total occlusion (CTO) in unselected patients presenting with ST-elevation myocardial infarction (MI) (STEMI) has not been characterized.

METHODS

Patients with STEMI referred with or without cardiogenic shock were categorized into no CTO, 1 CTO, and >1 CTO. The primary end point was the 30-day mortality.

RESULTS

Between 2006 and 2011, 2,020 consecutive patients were included. A total of 141 patients (7%) presented with cardiogenic shock on admission. The prevalence of 1 CTO and >1 CTO in a non-infarct-related artery was 23% and 5%, respectively, among patients with shock compared with 6% and 0.5% in patients without shock (P < .0001). Independent predictors of cardiogenic shock included left main-related MI (odds ratio [OR] 6.55, 95% CI 1.39-26.82, P = .019), CTO (OR 4.20, 95% CI 2.64-6.57, P < .001), creatinine clearance <60 mL/min (OR 3.41, 95% CI 2.32-4.99, P < .0001), and left anterior descending-related MI (OR 2.20, 95% CI 1.51-3.23, P < .0001). Thirty-day mortality was 100% in shock patients with >1 CTO, 65.6% with 1 CTO, and 40.2% in patients without CTO (P < .0001). After adjustment for left ventricular ejection fraction and renal function, CTO remained an independent predictor for 30-day mortality (hazard ratio [HR] 1.83; 95% CI 1.10-3.01, P = .02).

CONCLUSION

In patients with STEMI, CTO was strongly associated with cardiogenic shock on admission. In this setting, mortality was substantially higher in patients with 1 CTO and exceedingly high in those with >1 CTO. The presence of CTO was an independent predictor of early mortality.

The acutely occluded left main coronary artery culprit in cardiogenic shock and initial percutaneous coronary intervention: a substudy of the Manitoba “no option” left main PCI registry

We aim to describe the in-hospital outcomes of the first reported Canadian cohort of patients with cardiogenic shock and acute myocardial infarction (MI) due to acute and total occlusion of the left main coronary artery, treated with initial percutaneous coronary intervention (PCI). Acute left main thromboses with cardiogenic shock were identified (N = 8) from a retrospective consecutive cohort of high risk left main PCI (N = 56) performed at our institution from 2004–2009. The mean age was 62.3 ± 13.2 years, with 6 (75%) male patients. Successful PCI was performed in all patients, with thrombectomy utilized in 4 patients (50%), stenting in 7 patients (88%), and intra-aortic balloon pump augmentation in 7 patients (88%). Two patients (25%) required extracorporeal membrane oxygenation (ECMO) and 2 other patients required ventricular assist devices. Post-PCI coronary artery bypass grafting (CABG) was performed for 2 patients (25%). The mean SYNTAX score was 26.6 ± 10.5. The mean logistic EuroSCORE was 30.4 ± 12.6%. In-hospital mortality occurred in 3 patients (38%). Acute left main occlusion is a rare but devastating presentation of myocardial infarction, invariably with cardiogenic shock. Emergent PCI may be an effective method to acutely revascularize this subset of patients; however, aggressive post-PCI care including ECMO, CABG, and ventricular support may be required to improve patient survival.

Use and outcomes of multivessel percutaneous coronary intervention in patients with acute myocardial infarction complicated by cardiogenic shock (from the EHS-PCI Registry)

The value of multivessel percutaneous coronary intervention (MV-PCI) in patients with cardiogenic shock (CS) and multivessel disease (MVD) is still unclear because randomized controlled trials are missing. Therefore, we sought to evaluate the impact of MV-PCI on in-hospital outcomes of patients with MVD presenting with CS: 336 patients with acute myocardial infarction complicated by CS and ≥70% stenoses in ≥2 major epicardial vessels were included in this analysis of the Euro Heart Survey PCI registry. Patients undergoing MV-PCI (n = 82, 24%) were compared to those with single-vessel PCI (n = 254, 76%). The rate of 3-vessel disease (60% vs 57%, p = 0.63) was similar in the 2 cohorts. Presentation with resuscitation (48 vs 46%, p = 0.76) and ST-segment elevation myocardial infarction (83 vs 87%, p = 0.31) was frequent in patients with MV-PCI and single-vessel PCI. Patients with ventilation were more likely to receive MV-PCI (30% vs 19%, p = 0.05). There was a tendency toward a higher hospital mortality in patients with MV-PCI (48.8% vs 37.4%, p = 0.07). After adjustment for confounding variables, no significant difference for in-hospital mortality (odd ratio [OR] 1.28, 95% confidence interval [CI] 0.72 to 2.28) could be observed between the 2 groups. Age (OR 1.41, 95% CI 1.13 to 1.77), 3-vessel disease (OR 1.78, 95% CI 1.04 to 3.03), ventilation (OR 3.01, 95% CI 1.59 to 5.68), and previous resuscitation (OR 2.55, 95% CI 1.48 to 4.39) were independent predictors of hospital death. In conclusion, MV-PCI is currently used in only 1/4 of patients with CS and MVD. An additional nonculprit PCI was not associated with a survival benefit in these high risk patients.

Cardiogenic shock in ACS. Part 1: prediction, presentation and medical therapy

Ischemic cardiogenic shock is a complex, self-perpetuating pathological process that frequently causes death irrespective of medical therapy. Early definition of coronary anatomy is a pivotal step towards survival. Those destined to develop shock are likely to have three-vessel or left main stem disease with previously impaired left ventricular function. Early reperfusion of the occluded artery can limit infarct size, but ischemia-reperfusion injury or the 'no-reflow' phenomenon can preclude improvement in myocardial contractility. Emergence of shock depends upon the volume of ischemic myocardium, stroke volume, and peripheral vascular resistance. If cytokine release triggers the systemic inflammatory response, systemic vascular resistance falls and inadequate coronary perfusion pressure heralds the downward spiral. Survival depends on early recognition of shock, followed by aggressive targeted treatment of left, right, or biventricular failure. The goal is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial pressure, which is achieved with inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption, and extended ischemia. The value of intra-aortic balloon counter-pulsation is now questioned in patients with advanced shock. When mean arterial pressure is <55 mmHg with serum lactate >11 mmol/l, death is likely and mechanical circulatory support becomes the only chance for survival.

Mortality of patients with ST-segment elevation myocardial infarction and cardiogenic shock treated by PCI is correlated to the infarct-related artery--results from the PL-ACS Registry

BACKGROUND

Mortality of patients with ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock (CS) on admission remains high despite invasive treatment. The aim of this analysis was to assess the relationship between the infarct-related artery (IRA) and the early and 12-month outcomes of patients with STEMI and CS treated by percutaneous coronary intervention (PCI).

METHODS

Two thousand ninety patients with STEMI and CS registered in the prospective Polish Registry of Acute Coronary Syndromes from October 2003 to November 2009 were included.

RESULTS

The in-hospital mortality in the left main (LM), left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) groups was 64.7%, 41.0%, 36.0%, and 30.8%, respectively, with p<0.0001. The 12-month mortality in the LM, LAD, Cx, and RCA groups was 77.7%, 58.2%, 55.1%, and 45.0%, respectively, with p<0.0001. After multivariate adjustment, LM as the IRA was significantly associated with higher 12-month mortality (hazard ratio=1.71, 95% confidence interval=1.28-2.27, p=0.0002).

CONCLUSIONS

In-hospital and long-term mortality of patients with STEMI and CS treated by PCI are significantly correlated to the IRA, being highest for LM and lowest for RCA.

Cardiogenic shock in myocardial infarction-results of in-hospital follow-up

The purpose of this study was to present the outcomes of treatment of cardiogenic shock (CS) complicating acute myocardial infarction (AMI) among patients hospitalized from 1999 through 2006. The study enrolled 1003 patients. Group 1 comprised 87 patients presenting with AMI complicated with CS, whereas Group 2 comprised 916 patients presenting with AMI without CS symptoms. Determination of invasive treatment was according to standard guidelines. The endpoint comprised death, stroke, and reocclusion/reinfarction. Follow-up was confined to the intra-hospital period. CS was observed more frequently in cases of ST-elevation MI (STEMI) and right ventricular MI. The transportation and door-to-needle time were shorter in Group 1. CS patients were characterized by a more severe coronary artery disease, higher maximal creatinine kinase levels, lower global ejection fractions, and increased incidence of atrioventricular conduction disorders. The efficacy of percutaneous coronary intervention (PCI) was 82.26% in Group 1 and 95.03% in Group 2. Death occurred in 33.3% of CS patients and in 3.6% of AMI patients (p<0.0001). Our study proved that in a short-term follow-up, PCI is a procedure of high efficacy in CS patients. The short-term follow-up precluded a conclusion of statistically significant benefits from the shortening of the transportation and door-to-needle time.

Effect of multivessel coronary disease with or without concurrent chronic total occlusion on one-year mortality in patients treated with primary percutaneous coronary intervention for cardiogenic shock

Despite early revascularization, mortality remains high in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. It has been shown that the effect of multivessel disease (MVD) on mortality in patients with STEMI treated with primary percutaneous coronary intervention is mainly caused by the presence of chronic total occlusion (CTO) in a noninfarct-related coronary artery. Whether this association also exists in patients with STEMI with cardiogenic shock is unknown. In our institution, 292 consecutive patients with STEMI complicated by cardiogenic shock were admitted from 1997 to 2005 and treated with primary percutaneous coronary intervention. Patients were classified as having single vessel disease, MVD without CTO, and CTO. Cox regression analysis was used for multivariate analysis. The 1-year mortality rate of patients with single-vessel disease, MVD, and CTO was 31%, 47%, and 63%, respectively. After adjustment for possible confounders, MVD alone was not an independent predictor of 1-year mortality (hazard ratio 1.5, 95% confidence interval 0.98 to 2.3, p = 0.07). In contrast, CTO in a noninfarct-related artery was an independent predictor of 1-year mortality (hazard ratio 2.1, 95% confidence interval 1.5 to 3.1, p <0.01). In conclusion, the presence of CTO in a non-infarct-related artery was an independent predictor of 1-year mortality. In contrast, MVD alone lost its predictive significance after multivariate analysis.