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Hlinomaz O, Motovska Z, Kala P, Hromadka M, Precek J, Mrozek J, Červinka P, Kettner J, Matejka J, Zohoor A, Bis J, Jarkovsky J. Outcomes of patients with myocardial infarction and cardiogenic shock treated with culprit vessel-only versus multivessel primary PCI. Hellenic J Cardiol 2024; 76:1-10. [PMID: 37633488 DOI: 10.1016/j.hjc.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Multivessel primary percutaneous coronary intervention (pPCI) is still often used in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and multivessel coronary disease (MVD) treated with culprit vessel-only pPCI or multivessel-pPCI during the initial procedure. MATERIAL AND METHODS From 2016 to 2020, 23,703 primary PCI patients with STEMI were included in a national all-comers registry of cardiovascular interventions. Of them, 1,213 (5.1%) patients had CS and MVD at admission to the hospital. Initially, 921 (75.9%) patients were treated with culprit vessel (CV)-pPCI and 292 (24.1%) with multivessel (MV)-pPCI. RESULTS Patients with 3-vessel disease and left main disease had a higher probability of being treated with MV-pPCI than patients with 2-vessel disease and patients without left main disease (28.5% vs. 18.6%; p < 0.001 and 37.7% vs. 20.6%; p < 0.001). Intra-aortic balloon pump, extracorporeal membrane oxygenation (ECMO), and other mechanical circulatory support systems were more often used in patients with MV-pPCI. Thirty (30)-day and 1-year all-cause mortality rates were similar in the CV-pPCI and MV-pPCI groups (odds ratio, 1.01; 95% confidence interval [CI] 0.77 to 1.32; p = 0.937 and 1.1; 95% CI 0.84 to 1.44; p = 0.477). The presence of 3-vessel disease and the use of ECMO were the strongest adjusted predictors of 30-day and 1-year mortality. CONCLUSIONS Our data from an extensive all-comers registry suggests that selective use of MV-pPCI does not increase the all-cause mortality rate in patients with CS-STEMI and MVD compared to CV-pPCI.
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Affiliation(s)
- Ota Hlinomaz
- International Clinical Research Center and Department of Cardioangiology, St. Anne University Hospital and Masaryk University, Brno, Czech Republic
| | - Zuzana Motovska
- Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
| | - Petr Kala
- University Hospital Brno and Faculty of Medicine of Masaryk University, Department of Internal Medicine and Cardiology, Brno, Czech Republic
| | - Milan Hromadka
- University Hospital and Faculty of Medicine, Pilsen, Czech Republic
| | - Jan Precek
- University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Jan Mrozek
- University Hospital and Faculty of Medicine, Ostrava, Czech Republic
| | | | - Jiri Kettner
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Matejka
- Regional Hospital, Pardubice, Czech Republic
| | | | - Josef Bis
- University Hospital and Faculty of Medicine, Hradec Kralové, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses of Masaryk University, Brno, Czech Republic; Institute of Health Information and Statistics of the Czech Republic, Czech Republic
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Gill GS, Sánchez JS, Thandra A, Kanmanthareddy A, Alla VM, Garcia-Garcia HM. Multivessel vs. culprit-vessel only percutaneous coronary interventions in acute myocardial infarction and cardiogenic shock: a systematic review and meta-analysis of prospective randomized and retrospective studies. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:558-569. [PMID: 35680428 DOI: 10.1093/ehjacc/zuac072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 04/25/2022] [Accepted: 05/26/2022] [Indexed: 06/15/2023]
Abstract
AIMS Studies comparing outcomes of multivessel (MV) vs. culprit-vessel (CV) only percutaneous coronary intervention (PCI) during index cardiac catheterization in patients presenting with acute myocardial infarction (MI) and cardiogenic shock (CS) have reported conflicting results. In this systematic review we aim to investigate outcomes with MV vs. CV-only revascularization strategies in patients with acute MI and CS. METHODS AND RESULTS PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing MV vs. CV PCI in patients with acute MI and CS. Data were extracted and pooled by means of random effects model. Primary outcome was early all-cause mortality (up to 30 days), while the secondary outcomes included late all-cause mortality (mean, 11.4 months), stroke, new renal replacement therapy, reinfarction, repeat revascularization, and bleeding. Pooled odds ratio (OR), 95% confidence intervals (CIs), and number needed to harm (NNH) were calculated. A total of 16 studies enrolling 75 431 patients were included. The MV PCI was associated with higher risk of early mortality [OR 1.17, 95% CI (1.00-1.35); P = 0.04; NNH = 62], stroke [1.15 (1.03-1.29); P = 0.01; NNH = 351], and new renal replacement therapy [1.33 (1.06-1.67); P = 0.01; NNH = 61]; and with lower risk of repeat revascularization [0.61 (0.41-0.89); P = 0.01] when compared with CV PCI. No significant difference was observed in late-term mortality [1.02 (0.84-1.25); P = 0.84], risk of reinfarction [1.13 (0.94-1.35); P = 0.18], or bleeding [1.21 (0.94-1.55); P = 0.13] between groups. CONCLUSION Among patients with acute MI and CS, MV PCI during index cardiac catheterization was associated with higher risk of early mortality, stroke, and renal replacement therapy.
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Affiliation(s)
- Gauravpal S Gill
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Jorge Sanz Sánchez
- Hospital Universitari i Politecnic La Fe, Valencia, Spain
- Centro de Investigación Biomedica en Red (CIBERCV), Madrid, Spain
| | - Abhishek Thandra
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Arun Kanmanthareddy
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Venkata Mahesh Alla
- Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, NE, USA
| | - Hector M Garcia-Garcia
- Department of Medicine, Georgetown University, Washington, DC, USA
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
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Xiong B, Yang H, Yu W, Zeng Y, Han Y, She Q. 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. Front Cardiovasc Med 2022; 9:735636. [PMID: 35497976 PMCID: PMC9051032 DOI: 10.3389/fcvm.2022.735636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 02/28/2022] [Indexed: 11/22/2022] Open
Abstract
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.
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Acute Myocardial Infarction of the Left Main Coronary Artery Presenting with Cardiogenic Shock and Pulmonary Edema during Noncardiac Surgery. Case Rep Cardiol 2021; 2021:5460816. [PMID: 34430055 PMCID: PMC8380411 DOI: 10.1155/2021/5460816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 11/10/2020] [Accepted: 07/27/2021] [Indexed: 11/29/2022] Open
Abstract
Acute myocardial infarction (AMI) caused by severe stenosis of left main coronary artery (LMCA) presenting with cardiogenic shock and pulmonary edema during noncardiac surgery is uncommon, but a catastrophic event. A 77-year-old male with cholangiocarcinoma underwent hepatectomy. During the surgery, he presented with cardiogenic shock, which did not respond to infusion administration or vasopressor. A transesophageal echocardiogram revealed anterior, septal, and lateral severe hypokinesia and impaired left ventricular function. Emergent coronary angiogram showed severe stenosis of LMCA. The patient underwent primary percutaneous coronary intervention (PCI) under the support of intra-aortic balloon pump, followed by extracorporeal membrane oxygenation. The chest roentgenogram showed pulmonary edema. Two days after PCI, he successfully underwent hepatectomy and bile duct resection. Early identification of the cause of hemodynamic instability during noncardiac surgery and invasive strategy are important for minimizing the myocardial injury and improving clinical outcomes in AMI of LMCA.
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Hu MJ, Li XS, Jin C, Yang YJ. Does multivessel revascularization fit all patients with STEMI and multivessel coronary artery disease? A systematic review and meta-analysis. IJC HEART & VASCULATURE 2021; 35:100813. [PMID: 34169144 PMCID: PMC8209177 DOI: 10.1016/j.ijcha.2021.100813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/06/2021] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
Objective We sought to assess the relative merits of different revascularization strategies in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease complicated by cardiogenic shock or chronic total occlusion (CTO). Background Recent randomized trials and meta-analysis have suggested that multivessel percutaneous coronary intervention (PCI) is associated with better outcomes in patients with STEMI and multivessel coronary artery disease, however, patients complicated by cardiogenic shock or CTO were excluded. Methods Studies that compared multivessel PCI (immediate or staged) with culprit-only PCI in patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock or CTO were included. Random odd ratio (OR) and 95% confidence interval (CI) were conducted. Results Sixteen studies with 8695 patients complicated by cardiogenic shock and eight studies with 2259 patients complicated by CTO were included. In patients complicated by cardiogenic shock, a strategy of CO-PCI was associated with lower risk for short-term renal failure (OR: 0.75; 95% CI: 0.61–0.93; I2 = 0.0%), with no significant difference in MACE, all-cause mortality, re-infarction, revascularization, cardiac death, heart failure, major bleeding, or stroke compared with an immediate MV-PCI strategy. In patients complicated by CTO, a strategy of CO-PCI was associated with higher risk for long-term MACE (OR: 2.06; 95% CI: 1.39–3.06; I2 = 54.0%), all-cause mortality (OR: 2.89; 95% CI: 2.09–4.00; I2 = 0.0%), cardiac death (OR: 3.12; 95% CI: 2.05–4.75; I2 = 16.8%), heart failure (OR: 1.99; 95% CI: 1.22–3.24; I2 = 0.0%), and stroke (OR: 2.80; 95% CI: 1.04–7.53; I2 = 0.0%) compared with a staged MV-PCI strategy, without any difference in re-infarction, revascularization, or major bleeding. Conclusions For patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock, an immediate multivessel PCI was not advocated due to a higher risk for short-term renal failure, whereas for patients complicated by CTO, a staged multivessel PCI was advocated due to reduced risks for long-term MACE, all-cause mortality, cardiac death, heart failure, and stroke.
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Affiliation(s)
- Meng-Jin Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Xiao-Song Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chen Jin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
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Omer MA, Brilakis ES, Kennedy KF, Alkhouli M, Elgendy IY, Chan PS, Spertus JA. Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. JACC Cardiovasc Interv 2021; 14:1067-1078. [PMID: 33933384 DOI: 10.1016/j.jcin.2021.02.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock. BACKGROUND The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain. METHODS Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI 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 aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis. RESULTS Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20). CONCLUSIONS Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.
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Affiliation(s)
- Mohamed A Omer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
| | - Emmanouil S Brilakis
- Abbott Northwestern Hospital, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA
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Multivessel Intervention in Myocardial Infarction with Cardiogenic Shock: CULPRIT-SHOCK Trial Outcomes in the PL-ACS Registry. J Clin Med 2021; 10:jcm10091832. [PMID: 33922373 PMCID: PMC8122818 DOI: 10.3390/jcm10091832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/03/2021] [Accepted: 04/19/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Omer MA, Exaire JE, Jentzer JC, Sandoval YB, Singh M, Cagin CR, Elgendy IY, Tak T. Management of ST-Elevation Myocardial Infarction in High-Risk Settings. Int J Angiol 2021; 30:53-66. [PMID: 34025096 DOI: 10.1055/s-0041-1723941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Despite the widespread adoption of primary percutaneous intervention and modern antithrombotic therapy, ST-segment elevation myocardial infarction (STEMI) remains the leading cause of death in the United States and remains one of the most important causes of morbidity and mortality worldwide. Certain high-risk patients present a challenge for diagnosis and treatment. The widespread adoption of primary percutaneous intervention in addition to modern antithrombotic therapy has resulted in substantial improvement in the short- and long-term prognosis following STEMI. In this review, we aim to provide a brief analysis of the state-of-the-art treatment for patients presenting with STEMI, focusing on cardiogenic shock, current treatment and controversies, cardiac arrest, and diagnosis and treatment of mechanical complications, as well as multivessel and left main-related STEMI.
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Affiliation(s)
- Mohamed A Omer
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jose E Exaire
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Charles R Cagin
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Tahir Tak
- Cardiovascular Services, Mayo Clinic Health System, La Crosse, Wisconsin.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Vergara R, Vignini E, Ciabatti M, Migliorini A, Valenti R, Antoniucci D. Long-Term Mortality Comparison of Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock and Treated With Culprit-Only or Multivessel Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 22:10-15. [PMID: 32605903 DOI: 10.1016/j.carrev.2020.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/24/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We sought to determine whether, in a real word context of patients with Acute Myocardial Infarction (AMI), multivessel disease (MVD) and cardiogenic shock (CS), the successful treatment with primary percutaneous coronary intervention (p-PCI) of only culprit lesions (OC-PCI) is associated with better long-term mortality rates than multivessel PCI (MV-PCI) of all significant lesions. METHODS From our registry of all consecutive patients admitted for AMI between January 1995 and December 2016 we selected those presenting with CS and MVD successfully treated with p-PCI, and compared those who underwent OC-PCI against MV-PCI, either during the p-PCI (MV-pPCI) or by staged revascularization (Staged-PCI) during hospitalization. The primary endpoint was 2-year all-cause death. RESULTS Among 4210 patients with AMI, 406 (9.6%) presented CS (Killip class IV). A total of 292 patients had MVD. Of them, 252 (86.3%) were successfully treated with p-PCI, 159 patients with OC-PCI and 93 with MV-PCI, either in the same (n = 29) or staged procedure (n = 64). At 2-year follow-up the overall mortality was 47.6%, lower in MV-PCI group (37.6% vs 53.5% in OC-PCI, p = 0.019). Diabetes (HR = 1.50, 1.01-2.22), three vessel disease (HR = 1.49, 1.02-2.17) and basal left ventricular ejection fraction <15% (HR = 3.39, 2.41-6.27) were independent predictors of mortality, while MV-PCI was the only variable associated with improved survival (HR = 0.54, 0.36-0.81). CONCLUSIONS In this real world registry of AMI patients with MVD presenting CS, MV-PCI was associated with better long-term survival.
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Affiliation(s)
- Ruben Vergara
- Division of Cardiology, Careggi-Hospital, Florence, Italy.
| | - Elisa Vignini
- Division of Cardiology, Careggi-Hospital, Florence, Italy
| | | | | | - Renato Valenti
- Division of Cardiology, Careggi-Hospital, Florence, Italy
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Maznyczka AM, Ford TJ, Oldroyd KG. Revascularisation and mechanical circulatory support in patients with ischaemic cardiogenic shock. Heart 2019; 105:1364-1374. [PMID: 31129613 DOI: 10.1136/heartjnl-2018-313050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/20/2019] [Accepted: 03/24/2019] [Indexed: 11/04/2022] Open
Affiliation(s)
- Annette M Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Keith G Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
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Enezate T, Eniezat M, Thomas J. Utilization and Outcomes of Temporary Mechanical Circulatory Support Devices in Cardiogenic Shock. Am J Cardiol 2019; 124:505-510. [PMID: 31204034 DOI: 10.1016/j.amjcard.2019.05.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/03/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
Cardiogenic shock (CS) is associated with high morbidity and mortality despite recent advances in the temporary mechanical circulatory support (MCS) devices. The current utilization and outcomes of these MCS devices with or without vasopressors compared with conventional medical therapy (no-MCS) in CS remain poorly described. The study population was extracted from the 2014 Nationwide Readmissions Database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for CS, temporary MCS devices, and vasopressor infusion. Study end points included in-hospital all-cause mortality, length of index hospital stay (LOS), the likelihood of receiving invasive treatment, postprocedural bleeding, vascular complications, total hospitalization charges, and discharge disposition. A total of 59,148 discharges with a diagnosis of CS were identified (age 67 years; 38.5% female). Temporary MCS devices were utilized in 22.7%. The use of these devices was associated with lower in-hospital all-cause mortality (33.0% vs 39.7%, p <0.01), increased likelihood of invasive therapy (75.7% vs 26.3%, p <0.01), and increased likelihood of being discharged home (24.8% vs 20.6%, p <0.01). However, the MCS group had longer LOS (16.9 vs 12.1 days, p <0.01), higher vascular complications (2.6% vs 1.4%, p <0.01), bleeding (31.2% vs 16.8%, p <0.01), and total hospitalization charges ($374,574 vs $182,045, p <0.01). In conclusion, the use of the temporary MCS devices for the treatment of CS was associated with lower mortality, increased the likelihood of receiving invasive treatment and the likelihood of being discharged home. However, it was associated with higher in-hospital complications, LOS, and hospitalization charges.
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Abstract
Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion primarily due to cardiac dysfunction. This condition is the most common cause of death in patients affected by acute myocardial infarction (AMI). Despite early revascularization, prompt optimal medical therapy, and up-to-date mechanical circulatory supports, mortality of patients with CS remains high.The objective of this review is to summarize epidemiology, pathophysiology, and treatment options of CS in light of the new European Society of Cardiology (ESC) recommendations. The latest European guidelines on myocardial revascularization have reviewed the previous guidelines with respect to early multivessel revascularization and routine use of intra-aortic balloon pump (IABP) in patients with AMI-related CS.Most of the current evidences come partly from randomized trials, but mostly from observational registries because of the difficulty to test different treatments in this life-threatening clinical setting.Some of the latest studies highlight the potential crucial benefit of newly introduced mechanical circulatory support devices, although evidences are not sufficient to definitely assess the benefit/risk ratio of the different systems.Many questions remain unanswered in this field, and further trials are advocated to better elucidate the best medical, reperfusion, and circulatory support approaches aimed to improve the poor prognosis of patients with CS after AMI.
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Khan MS, Siddiqi TJ, Usman MS, Riaz H, Khan AR, Murad MH, Kalra A, Figueredo VM, Bhatt DL. Meta-analysis Comparing Culprit Vessel Only Versus Multivessel Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction and Cardiogenic Shock. Am J Cardiol 2019; 123:218-226. [PMID: 30420183 DOI: 10.1016/j.amjcard.2018.09.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/19/2018] [Accepted: 09/25/2018] [Indexed: 12/29/2022]
Abstract
Cardiogenic shock (CS) after a myocardial infarction continues to be associated with high mortality. Whether percutaneous coronary intervention (PCI) of noninfarct coronary arteries (multivessel intervention [MVI]) improves outcomes in CS after acute myocardial infarction (AMI) remains controversial. MEDLINE, Cochrane CENTRAL, and Scopus databases were searched for original studies comparing MVI with culprit-vessel intervention (CVI) in AMI patients with multivessel disease and CS. Risk ratios (RRs) and 95% confidence intervals were calculated and pooled using a random effects model. Thirteen studies, consisting of 7,906 patients (nMVI = 1,937; nCVI = 5,969), were included in this meta-analysis. Overall, the MVI and CVI groups did not differ significantly in the risk of short-term mortality (RR: 1.06 [0.91, 1.23]; p = 0.45; I2 = 75.82%), long-term mortality (RR: 0.93 [0.78, 1.11]; p = 0.37; I2 = 67.92%), reinfarction (RR: 1.16 [0.75, 1.79]; p = 0.50; I2 = 0%), revascularization (RR: 0.84 [0.48, 1.47]; p = 0.54; I2 = 83.01%), bleeding (RR: 1.15 [0.96, 1.38]; p = 0.09, I2 = 0%), or stroke (RR: 1.29 [0.86, 1.94]; p = 0.80, I2 = 0%). However, significantly increased risk of renal failure was seen in the MVI group (RR: 1.35 [1.10, 1.66]; p = 0.004; I2 = 0%). On subgroup analysis, it was seen that results from retrospective studies showed higher short-term mortality in the MVI group in comparison with prospective studies (p = 0.003). The certainty in estimates is low due to the largely observational nature of the evidence. In conclusion, MVI provides no additional reduction in short- or long-term mortality in AMI patients with multivessel disease and CS. Additionally, the risk of renal failure may be higher with the use of MVI.
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Kundu A, Sardar P, Kakouros N, Malhotra R, Kolte D, Feldman DN, Abbott JD, Fisher DZ. Outcomes of multivessel vs culprit lesion-only percutaneous coronary intervention in patients with acute myocardial infarction complicated by cardiogenic shock: Evidence from an updated meta-analysis. Catheter Cardiovasc Interv 2018; 94:70-81. [DOI: 10.1002/ccd.28062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/07/2018] [Accepted: 12/16/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Amartya Kundu
- Division of Cardiovascular Medicine; University of Massachusetts Medical School; Worcester Massachusetts
| | - Partha Sardar
- Division of Cardiovascular Medicine; Brown University; Providence Rhode Island
| | - Nikolaos Kakouros
- Division of Cardiovascular Medicine; University of Massachusetts Medical School; Worcester Massachusetts
| | - Rohit Malhotra
- Division of Cardiovascular Medicine; University of Massachusetts Medical School; Worcester Massachusetts
| | - Dhaval Kolte
- Division of Cardiovascular Medicine; Massachusetts General Hospital; Boston Massachusetts
| | - Dmitriy N. Feldman
- Division of Cardiovascular Medicine; Weill Cornell Medical College; New York New York
| | - JD Abbott
- Division of Cardiovascular Medicine; Brown University; Providence Rhode Island
| | - Daniel Z. Fisher
- Division of Cardiovascular Medicine; University of Massachusetts Medical School; Worcester Massachusetts
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Khalid MF, Khan AA, Khattak F, Ayub MT, Bagai J, Mukherjee D, Helton T, Cohen MG, Banerjee S, Paul TK. Culprit Vessel Only Versus Multivessel Percutaneous Coronary Intervention in Acute Myocardial Infarction with Cardiogenic Shock: A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:956-964. [PMID: 30638891 DOI: 10.1016/j.carrev.2018.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/05/2018] [Accepted: 12/18/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previous studies comparing outcomes between culprit vessel only percutaneous coronary intervention (CV-PCI) versus multivessel percutaneous coronary intervention (MV-PCI) in patients with cardiogenic shock in the setting of acute myocardial infarction have shown conflicting results. This meta-analysis investigates the optimal approach for management of these patients considering recently published data. METHODS Electronic databases including MEDLINE, ClinicalTrials.gov and the Cochrane Library were searched for all clinical studies published until May 1, 2018, which compared outcomes in patients presenting with acute myocardial infarction and cardiogenic shock. Studies comparing CV-PCI versus MV-PCI in patients with multivessel coronary artery disease were screened for inclusion in final analysis. The primary end point was in-hospital/30 day mortality. Secondary endpoints included long term (>6 months) mortality, renal failure requiring renal replacement therapy, stroke, bleeding, and recurrent myocardial infarction. Odds ratio (OR) with 95% of confidence interval (CI) were computed and p values <0.05 were considered significant. RESULTS Patient who underwent CV-PCI had significantly lower short-term mortality (in-hospital or 30-day mortality) (OR: 0.73, CI: 0.61-0.87, p = 0.0005), and lower odds of severe renal failure requiring renal replacement therapy (OR: 0.76, CI: 0.59-0.98, p = 0.03). There was no statistically significant difference in long-term mortality, stroke, bleeding, and recurrent myocardial infarction between two groups. CONCLUSION This meta-analysis showed lower short-term mortality and decreased odds of renal failure requiring renal replacement therapy with CV-PCI compared to MV-PCI. However, subgroup analysis including studies exclusively assessing STEMI patients revealed no statistically significant difference in outcomes. Further randomized trials are needed to confirm these findings and evaluate long term results.
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Affiliation(s)
| | - Abdul Ahad Khan
- Division of Cardiovascular Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Furqan Khattak
- Division of Cardiovascular Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Muhammad Talha Ayub
- Department of Internal Medicine, John H. Stroger Cook County Hospital, Chicago, IL, USA
| | - Jayant Bagai
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Debabrata Mukherjee
- Division of Cardiology, Department of Internal Medicine, Texas Tech University, TX, USA
| | - Thomas Helton
- Division of Cardiovascular Medicine, Veterans Affairs Mountain Home, Johnson City, TN, USA
| | - Mauricio G Cohen
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, USA
| | - Subhash Banerjee
- VA North Texas Health Care System, University of Texas Southwestern Medical Center at Dallas, TX, USA
| | - Timir K Paul
- Division of Cardiovascular Medicine, East Tennessee State University, Johnson City, TN, USA.
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16
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Bertaina M, Ferraro I, Omedè P, Conrotto F, Saint-Hilary G, Cavender MA, Claessen BE, Henriques JP, Frea S, Usmiani T, Grosso Marra W, Pennone M, Moretti C, D'Amico M, D'Ascenzo F. Meta-Analysis Comparing Complete or Culprit Only Revascularization in Patients With Multivessel Disease Presenting With Cardiogenic Shock. Am J Cardiol 2018; 122:1661-1669. [PMID: 30220420 DOI: 10.1016/j.amjcard.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/30/2018] [Accepted: 08/07/2018] [Indexed: 12/31/2022]
Abstract
The optimal strategy for patients with an acute myocardial infarction (MI) and multivessel (MV) coronary artery disease complicated by cardiogenic shock (CS) remains unknown. We conducted a meta-analysis of all randomized controlled trials and observational studies that reported adjusted effect measures to evaluate the association of MV-PCI (percutaneous coronary intervention), compared with culprit only (C)-PCI, with cardiovascular events in patients admitted for CS and MV disease. We identified 12 studies (n = 1 randomized controlled trials, n = 11 observational) that included 7,417 patients (n = 1,809 treated with MV-PCI and n = 5,608 with C-PCI). When compared with C-PCI, MV-PCI was not associated with an increased risk of short-term death (odds ratio [OR] 1.14, 95% confidence interval [CI] 0.87 to 1.48, p = 0.35 and adjusted OR [ORadj] 1.00, 95% CI 0.70 to 1.43, p = 1.00). In-hospital and/or short-term mortality tended to be higher with MV-PCI, when compared with C-PCI, for CS patients needing dialysis (ß 0.12, 95% CI from 0.049 to 0.198; p= 0.001), whereas MV-PCI was associated with lower in-hospital and/or short-term mortality in patients with an anterior MI (ß -0.022, 95% CI -0.03 to -0.01; p <0.001). MV-PCI strategy was associated with a more frequent need for dialysis or contrast-induced nephropathy after revascularization (OR 1.36, 95% CI 1.06 to 1.75, p = 0.02). In conclusion, MV-PCI seems not to increase risk of death during short- or long-term follow-up when compared with C-PCI in patients admitted for MV coronary artery disease and MI complicated by CS. Furthermore, it appears a more favorable strategy in patients with anterior MI, whereas the increased risk for AKI and its negative prognostic impact should be considered in decision-making process. Further studies are needed to confirm our hypothesis on in these subpopulations of CS patients.
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Abstract
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.
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Affiliation(s)
- Deepak Acharya
- From the Section of Advanced Heart Failure, Mechanical Circulatory Support, and Pulmonary Vascular Disease, University of Alabama at Birmingham, Birmingham, AL
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18
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Kim Y, Jeong MH, Ahn Y, Kim JH, Hong YJ, Sim DS, Kim MC, Kim HS, Park SJ, Gwon HC, Yun KH, Oh SK, Kim CJ, Cho MC. Results of a 10-Year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial Infarction (from the Korea Acute Myocardial Infarction Registry). Am J Cardiol 2018; 122:365-373. [PMID: 30041888 DOI: 10.1016/j.amjcard.2018.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/05/2018] [Accepted: 04/06/2018] [Indexed: 10/17/2022]
Abstract
Limited information exists about characteristics of patients with acute myocardial infarction (AMI) in Asia. We examined trends in interventional treatment and clinical outcomes for AMI from the Korea Acute Myocardial Infarction Registry (KAMIR). The study population was derived from patients in the KAMIR from November 2005 to December 2016. We identified 54,402 patients with ST-elevation myocardial infarction (STEMI) (n = 29,222) and non-ST-elevation myocardial infarction (NSTEMI) (n = 25,180). The rate of percutaneous coronary intervention (PCI) increased to 96.2% of STEMI group and 84.3% of NSTEMI group in 2016, respectively (All ptrend <0.001). Furthermore, the rate of successful PCI was 97.3% in STEMI and 97.9% in NSTEMI. The rate of primary PCI increased from 67.8% in 2005 to 96.9% in 2016 (ptrend <0.001). Moreover, in patients with STEMI, the proportion of drug-eluting stent implantation increased from 88.8% in 2005 to 97.9% in 2016 (ptrend <0.001). Regarding 1-year clinical outcomes, incidence of definite stent thrombosis was 0.5%, 0.6%, and 0.4% in patients with AMI, STEMI, and NSTEMI, respectively. Moreover, 1-year mortality of AMI improved almost 40% compared with in 2005 (11.4% in 2005 and 6.7% in 2015, ptrend <0.001). In Korean patients with AMI, the rate of primary PCI and drug-eluting stent implantation in STEMI was evidently higher than in the Western registries. In 1-year clinical outcomes, the incidence of stent thrombosis was low and mortality of AMI gradually improved and was lower than in the Western registries.
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19
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de Waha S, Zeymer U, Fuernau G, Desch S, Thiele H. Revascularization Strategies in Patients With Acute MI and Cardiogenic Shock. J Am Coll Cardiol 2018; 71:2985-2986. [PMID: 29929626 DOI: 10.1016/j.jacc.2018.03.538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 02/28/2018] [Accepted: 03/06/2018] [Indexed: 11/25/2022]
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20
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Rahman H, Khan SU, Lone AN, Kaluski E. Revascularization strategies in cardiogenic shock complicating acute myocardial infarction: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:647-654. [PMID: 29909948 DOI: 10.1016/j.carrev.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/24/2018] [Accepted: 06/06/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal revascularization strategy in patients with multi-vessel disease (MVD) presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remains unclear. OBJECTIVE To investigate the comparative differences between culprit-only revascularization (COR) versus instant multi-vessel revascularization (IMVR) in AMI and CS. METHODS 13 studies were selected using MEDLINE, EMBASE and the CENTRAL (Inception - 31 November2017). Outcomes were assessed at short-term (in-hospital or ≤30 days duration) and long-term duration (≥6 months). Estimates were reported as random effects relative risk (RR) with 95% confidence interval (CI). RESULTS In analysis of 7311 patients, COR significantly reduced the relative risk of short-term all-cause mortality (RR: 0.87; 95% CI, 0.77-0.97; p = 0.01, I2 = 50%) and renal failure (RR: 0.75; 95% CI, 0.61-0.94; p = 0.01, I2 = 7%) compared with IMVR. There were no significant differences between both the strategies in terms of reinfarction (RR: 1.25; 95% CI, 0.59-2.63; p = 0.56, I2 = 0%), major bleeding (RR: 0.88; 95% CI, 0.75-1.04; p = 0.14, I2 = 0%) and stroke (RR: 0.77; 95% CI, 0.50-1.17; p = 0.22, I2 = 0%) at short term duration. Similarly, no significant differences were observed between both groups regarding all-cause mortality (RR; 1.01; 95% CI, 0.85-1.20; p = 0.93, I2 = 61%) and reinfarction (RR: 0.71; 95% CI, 0.34-1.47; p = 0.35, I2 = 26%) at long term duration. CONCLUSION In MVD patients presenting with AMI and CS, IMVR was comparable to COR in terms of all-cause mortality at long term follow up duration. These results are predominantly derived from observational data and more randomized controlled trials are required to validate this impression.
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Affiliation(s)
- Hammad Rahman
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA.
| | - Safi U Khan
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA
| | - Ahmad N Lone
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA
| | - Edo Kaluski
- Guthrie Health System/Robert Packer Hospital, Sayre, PA, USA; Rutgers New Jersey Medical School, Newark, NJ, USA; The Geisinger Commonwealth Medical College, Scranton, PA, USA
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21
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Complete Versus Culprit-Only Revascularization in STEMI: a Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:41. [PMID: 29627944 DOI: 10.1007/s11936-018-0636-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW In ST-segment elevation myocardial infarction, urgent revascularization of the culprit coronary vessel and restoration of coronary flow is the goal of the initial management. However, obstructive non-culprit disease is frequently concomitantly found during initial angiography and portends a poor prognosis. Management of non-culprit lesions in ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive debate. This review will examine the currently available evidence, with a specific focus on randomized clinical trials performed to date. RECENT FINDINGS Although early observational data suggested better outcomes with culprit-only revascularization, more recent data from several randomized trials have suggested improved outcomes with complete multivessel revascularization, either during the index PCI procedure or as a staged procedure. Data from recent randomized controlled trials have suggested the superiority of complete or multivessel revascularization and have subsequently led to changes to the most recent iterations of STEMI guidelines. However, the optimal management and timing of revascularization of non-culprit lesions in STEMI remain controversial.
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22
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Patel H, Nazeer H, Yager N, Schulman-Marcus J. Cardiogenic Shock: Recent Developments and Significant Knowledge Gaps. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:15. [PMID: 29478105 DOI: 10.1007/s11936-018-0606-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Patients with cardiogenic shock (CS) continue to have high rates of morbidity and mortality. We aimed to describe current principles in the management of CS including coronary revascularization, medical management, mechanical circulatory support, and supportive care. RECENT FINDINGS Revascularization is still recommended, but trials have not found a benefit in the revascularization of nonculprit artery lesions. New mechanical circulatory support options are available, but optimal use remains uncertain. Overall improvement in outcomes appears to have plateaued. There remain substantial knowledge gaps about the management of CS. The ideal timing and selection criteria for mechanical support remain under-developed. There has been little systematic study to inform medical management or supportive care of this patient population. A more expansive research focus is necessary to improve the care of CS.
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Affiliation(s)
- Hiren Patel
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA
| | - Haider Nazeer
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA
| | - Neil Yager
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA
| | - Joshua Schulman-Marcus
- Division of Cardiology, Albany Medical Center, 47 New Scotland Avenue, MC-44, Albany, NY, 12208, USA.
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23
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Lee JM, Rhee TM, Hahn JY, Kim HK, Park J, Hwang D, Choi KH, Kim J, Park TK, Yang JH, Song YB, Choi JH, Choi SH, Koo BK, Kim YJ, Chae SC, Cho MC, Kim CJ, Gwon HC, Kim JH, Kim HS, Jeong MH. Multivessel Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction With Cardiogenic Shock. J Am Coll Cardiol 2018; 71:844-856. [DOI: 10.1016/j.jacc.2017.12.028] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/20/2017] [Accepted: 12/11/2017] [Indexed: 11/15/2022]
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24
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Janssens U. [Percutaneous coronary interventions in infarct-related shock and multivessel disease : Only treat the infarct-related vessel or treat all relevant coronary stenoses?]. Med Klin Intensivmed Notfmed 2017; 113:309-312. [PMID: 29147727 DOI: 10.1007/s00063-017-0383-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/02/2017] [Indexed: 11/26/2022]
Affiliation(s)
- U Janssens
- Klinik für Innere Medizin, St.-Antonius-Hospital, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland.
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25
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Affiliation(s)
- Anthony H. Gershlick
- From the Leicester Cardiovascular Biomedical Research Centre, University Hospitals of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Amerjeet S. Banning
- From the Leicester Cardiovascular Biomedical Research Centre, University Hospitals of Leicester, Glenfield Hospital, Leicester, United Kingdom
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26
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Kolte D, Sardar P, Khera S, Zeymer U, Thiele H, Hochadel M, Radovanovic D, Erne P, Hambraeus K, James S, Claessen BE, Henriques JP, Mylotte D, Garot P, Aronow WS, Owan T, Jain D, Panza JA, Frishman WH, Fonarow GC, Bhatt DL, Aronow HD, Abbott JD. Culprit Vessel–Only Versus Multivessel Percutaneous Coronary Intervention in Patients With Cardiogenic Shock Complicating ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005582. [PMID: 29146672 DOI: 10.1161/circinterventions.117.005582] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 09/21/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Dhaval Kolte
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Partha Sardar
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Sahil Khera
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Uwe Zeymer
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Holger Thiele
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Matthias Hochadel
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Dragana Radovanovic
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Paul Erne
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Kristina Hambraeus
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Stefan James
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Bimmer E. Claessen
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Jose P.S. Henriques
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Darren Mylotte
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Philippe Garot
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Wilbert S. Aronow
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Theophilus Owan
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Diwakar Jain
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Julio A. Panza
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - William H. Frishman
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Gregg C. Fonarow
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Deepak L. Bhatt
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - Herbert D. Aronow
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
| | - J. Dawn Abbott
- From the Department of Medicine, Division of Cardiology, Brown University, Providence, RI (D.K., H.D.A., J.D.A.); Department of Medicine, Division of Cardiology, University of Utah, Salt Lake City (P.S., T.O.); Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla (S.K., W.S.A., D.J., J.A.P., W.H.F.); Department of Cardiology, Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z., M.H.); Department of Cardiology, University Heart
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de Waha S, Desch S, Fuernau G, Pöss J, Ledwoch J, Jobs A, Eitel I, Thiele H. Interventional therapies in acute myocardial infarction complicated by cardiogenic shock. Herz 2017; 42:11-17. [PMID: 27909767 DOI: 10.1007/s00059-016-4511-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiogenic shock remains the most common cause of death in patients with acute myocardial infarction. Early revascularization of the infarct-related artery has been shown to reduce mortality and is the therapeutic cornerstone. The optimal revascularization strategy of additional non-culprit lesions remains yet to be determined. Further, uncertainties exist with respect to access site choice, antiplatelet regimen as well as mechanical support devices. This review outlines current evidence on the interventional management of cardiogenic shock complicating acute myocardial infarction.
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Affiliation(s)
- S de Waha
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany. .,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany.
| | - S Desch
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - G Fuernau
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - J Pöss
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - J Ledwoch
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - A Jobs
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - I Eitel
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - H Thiele
- University Heart Center Luebeck, Department of Cardiology, Angiology, and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Luebeck, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
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28
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Watanabe H, Morimoto T, Shiomi H, Kawaji T, Furukawa Y, Nakagawa Y, Ando K, Kadota K, Kimura T. Chronic total occlusion in non-infarct-related artery is associated with increased short-and long-term mortality in patients with ST-segment elevation acute myocardial infarction complicated by cardiogenic shock (from the CREDO-Kyoto AMI registry). Catheter Cardiovasc Interv 2017; 92:455-463. [DOI: 10.1002/ccd.27330] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/17/2017] [Accepted: 08/20/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Hiroki Watanabe
- Department of Cardiovascular Medicine; Graduate School of Medicine, Kyoto University; Japan
| | - Takeshi Morimoto
- Division of Clinical Epidemiology; Hyogo College of Medicine; Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine; Graduate School of Medicine, Kyoto University; Japan
| | - Tetsuma Kawaji
- Department of Cardiovascular Medicine; Graduate School of Medicine, Kyoto University; Japan
| | - Yutaka Furukawa
- Division of Cardiology; Kobe City Medical Center General Hospital; Japan
| | | | - Kenji Ando
- Division of Cardiology; Kokura Memorial Hospital; Japan
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine; Graduate School of Medicine, Kyoto University; Japan
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29
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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 933] [Impact Index Per Article: 133.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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30
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de Waha S, Jobs A, Eitel I, Pöss J, Stiermaier T, Meyer-Saraei R, Fuernau G, Zeymer U, Desch S, Thiele H. Multivessel versus culprit lesion only percutaneous coronary intervention in cardiogenic shock complicating acute myocardial infarction: A systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:28-37. [DOI: 10.1177/2048872617719640] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Early revascularisation of the culprit lesion is the therapeutic cornerstone in cardiogenic shock complicating acute myocardial infarction. The optimal management of additional non-culprit lesions is unclear. This systematic review and meta-analysis aims to summarise current evidence on the comparison of immediate multivessel percutaneous coronary intervention (MV-PCI) or culprit lesion only PCI with possible staged revascularisation (C-PCI) in patients with cardiogenic shock complicating acute myocardial infarction. Methods: Medical literature databases were screened to identify analyses comparing MV-PCI with C-PCI in patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease. In absence of randomised trials, 10 cohort studies were included in the current meta-analysis. The primary outcome of short-term mortality was assessed at hospital discharge or 30 days after hospital admission. Secondary outcomes were long-term mortality as well as myocardial re-infarction, stroke, acute renal failure, and bleeding at short-term follow-up. Results: Of 6051 patients, 1194 (19.7%) received MV-PCI and 4857 (80.3%) C-PCI. Short-term mortality was 37.5% in patients undergoing MV-PCI compared with 28.8% in C-PCI patients (risk ratio 1.26, 95% confidence interval 1.12–1.41, p=0.001). Long-term mortality ( p=0.77), myocardial re-infarction ( p=0.77), stroke ( p=0.12), acute renal failure ( p=0.17) and bleeding ( p=0.53) did not differ significantly between the two revascularisation groups. Conclusions: Results of this first meta-analysis on the interventional management of patients with cardiogenic shock complicating acute myocardial infarction and multivessel coronary artery disease do not support MV-PCI over C-PCI. However, possible treatment selection bias in the individual studies must be taken into account.
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Affiliation(s)
- Suzanne de Waha
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Alexander Jobs
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Ingo Eitel
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Janine Pöss
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Thomas Stiermaier
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Roza Meyer-Saraei
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Georg Fuernau
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
| | - Steffen Desch
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
| | - Holger Thiele
- University Heart Centre Luebeck, Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Luebeck, Luebeck, Germany
- Heart Centre Leipzig, Department of Internal Medicine/Cardiology, University of Leipzig, Leipzig, Germany
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31
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Krishnan SK, Riley RF, Hira RS, Lombardi WL. Multivessel Revascularization in Shock and High-Risk Percutaneous Coronary Intervention. Interv Cardiol Clin 2017; 6:407-416. [PMID: 28600093 DOI: 10.1016/j.iccl.2017.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review explores the usefulness of multivessel revascularization with percutaneous coronary intervention in patients with multivessel obstructive coronary artery disease (CAD) presenting with and without cardiogenic shock. We also evaluate the literature regarding complete versus incomplete revascularization for patients with cardiogenic shock, acute coronary syndromes, and stable coronary artery disease.
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Affiliation(s)
- Sandeep K Krishnan
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Robert F Riley
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Ravi S Hira
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - William L Lombardi
- Division of Cardiology, University of Washington, School of Medicine, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
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Abstract
Cardiogenic shock represents a state of low cardiac output and systemic hypoperfusion resulting in insufficient end-organ perfusion and consequent multiorgan failure. The main cause of this complication in the context of acute ST-elevation myocardial infarction is left ventricular dysfunction secondary to poor myocardial perfusion. In over 50% of cardiogenic shock cases, there is evidence of significant coronary stenosis within noninfarct-related arteries. Persistent ischemia in the noninfarct territory may contribute to ongoing hypotension. Currently, ESC and ACC/AHA/SCAI guidelines advocate complete revascularization in the context of multivessel coronary artery disease in the context of cardiogenic shock, although the evidence is weak.
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33
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Ko BS, Drakos SG, Welt FGP, Shah RU. Controversies and Challenges in the Management of ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock. Interv Cardiol Clin 2017; 5:541-549. [PMID: 28582002 DOI: 10.1016/j.iccl.2016.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The prognosis in ST-elevation myocardial infarction has improved with coronary care units, revascularization, and anticoagulant strategies; however, cardiogenic shock (CS) remains a highly fatal condition. Controversies remain about optimal pharmacologic therapies, revascularization strategies, the role of mechanical circulatory support (MCS), and evidence-based patient selection. The current informed consent paradigm for clinical trials creates challenges testing treatments in CS patients, who are too ill to consent and require immediate treatment. Several trials are underway comparing revascularization strategies and MCS options. Although the prognosis is grim, careful, new and existing treatments could change the course of this condition in the coming years.
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Affiliation(s)
- Byung-Soo Ko
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Frederick G P Welt
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah School of Medicine, 30 North 1900 East, Room 4A100, Salt Lake City, UT 84132, USA.
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34
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Tarantini G, D'Amico G, Tellaroli P, Colombo C, Brener SJ. Meta-Analysis of the Optimal Percutaneous Revascularization Strategy in Patients With Acute Myocardial Infarction, Cardiogenic Shock, and Multivessel Coronary Artery Disease. Am J Cardiol 2017; 119:1525-1531. [PMID: 28341358 DOI: 10.1016/j.amjcard.2017.02.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/06/2017] [Accepted: 02/06/2017] [Indexed: 11/18/2022]
Abstract
The optimal percutaneous coronary intervention (PCI) revascularization strategy in patients with multivessel (MV) coronary artery disease (CAD) who present with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) has not been systematically addressed. Accordingly, we performed a study-level meta-analysis comparing 2 PCI strategies in these patients-infarct-related artery (IRA) only versus MV revascularization. Studies including patients with AMI and MV CAD complicated with CS who received primary PCI were searched from 2000 to 2016. The primary end points were in-hospital/30-day and mid- to long-term (≥6 month) mortality. Fixed and random effects models were used for analysis. Ten studies (9 prospective and 1 retrospective) involving 6,068 patients met our inclusion criteria. IRA-only PCI was the most frequently used revascularization strategy (4,872 patients, 80%), while MV PCI was performed in 1,196 patients (20%). The MV PCI strategy was associated with higher short-term mortality compared with the IRA-only PCI strategy (odds ratio 1.41, 95% confidence interval 1.15 to 1.71, p = 0.008). There was no difference in mid- to long-term mortality between MV PCI and IRA-only strategies (odds ratio 1.02, 95% confidence interval 0.65 to 1.58, p = 0.94). In conclusion, in patients with AMI and MV CAD complicated by CS, the IRA-only PCI strategy seems to be associated with lower short-term, but not mid- to long-term mortality compared with MV PCI. This finding is different from the revascularization strategy recommended by current professional guidelines and suggests the need for dedicated randomized clinical trials.
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Affiliation(s)
- Giuseppe Tarantini
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy.
| | - Gianpiero D'Amico
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Paola Tellaroli
- Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Claudia Colombo
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Sorin J Brener
- Department of Medicine, Cardiac Catheterization Laboratory, New York Methodist Hospital, Brooklyn, New York
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35
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Prognostic Analysis for Cardiogenic Shock in Patients with Acute Myocardial Infarction Receiving Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8530539. [PMID: 28251160 PMCID: PMC5303841 DOI: 10.1155/2017/8530539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/04/2017] [Indexed: 11/17/2022]
Abstract
Cardiogenic shock (CS) is uncommon in patients suffering from acute myocardial infarction (AMI). Long-term outcome and adverse predictors for outcomes in AMI patients with CS receiving percutaneous coronary interventions (PCI) are unclear. A total of 482 AMI patients who received PCI were collected, including 53 CS and 429 non-CS. Predictors for AMI patients with CS including recurrent MI, cardiovascular (CV) mortality, all-cause mortality, and repeated-PCI were analyzed. The CS group had a lower central systolic pressure and central diastolic pressure (both P < 0.001). AMI patients with hypertension history were less prone to develop CS (P < 0.001). Calcium channel blockers and statins were less frequently used by the CS group than the non-CS group (both P < 0.05) after discharge. Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, CV mortality, and all-cause mortality were higher in the CS group than the non-CS group (all P < 0.005). For patients with CS, stroke history was a predictor of recurrent MI (P = 0.036). CS, age, SYNTAX score, and diabetes were predictors of CV mortality (all P < 0.05). CS, age, SYNTAX score, and stroke history were predictors for all-cause mortality (all P < 0.05). CS, age, and current smoking were predictors for repeated-PCI (all P < 0.05).
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36
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Hemradj VV, Ottervanger JP, van 't Hof AW, Dambrink JH, Gosselink M, Kedhi E, Suryapranata H. Cardiogenic Shock Predicts Long-term Mortality in Hospital Survivors of STEMI Treated With Primary Percutaneous Coronary Intervention. Clin Cardiol 2016; 39:665-669. [PMID: 27775864 DOI: 10.1002/clc.22580] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) has a poor prognosis. Recently published data suggested, however, that CS does not affect long-term mortality in hospital survivors of STEMI. We investigated whether this could be confirmed in a larger cohort. HYPOTHESIS STEMI complicated by CS leads to worse long-term survival. METHODS A prospective cohort study was performed in 7412 consecutive patients with STEMI treated by primary percutaneous coronary intervention (angioplasty). The predictive value of CS on long-term mortality was assessed in hospital survivors. Multivariate analysis, adjusting for differences in baseline variables, was performed to assess the independent prognostic value of CS. RESULTS Cardiogenic shock was observed in 387 patients (5.2%). The total in-hospital mortality was 254 (3.4%), and mortality was significantly higher in patients with CS (20.0% vs 2.6%; P < 0.001). The 1-year mortality in hospital survivors was 10.3% in patients with CS and 3.9% in patients without CS (P < 0.001). After multivariate analysis, CS was still a significant predictor of long-term mortality in hospital survivors (hazard ratio: 2.6, 95% confidence interval: 1.64-4.01). CONCLUSIONS Cardiogenic shock remains a strong predictor of long-term mortality in hospital survivors of STEMI treated by primary percutaneous coronary intervention.
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Affiliation(s)
- Veemal V Hemradj
- Department of Cardiology, Isala Heart Centre, Zwolle, the Netherlands
| | | | | | - Jan Henk Dambrink
- Department of Cardiology, Isala Heart Centre, Zwolle, the Netherlands
| | - Marcel Gosselink
- Department of Cardiology, Isala Heart Centre, Zwolle, the Netherlands
| | - Elvin Kedhi
- Department of Cardiology, Isala Heart Centre, Zwolle, the Netherlands
| | - Harry Suryapranata
- Department of Cardiology, Isala Heart Centre, Zwolle, the Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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37
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Abstract
Approximately 50 % of hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and up to 80 % of patients with infarction-related cardiogenic shock have multivessel coronary artery disease. The optimal revascularization strategy in these patients has still not been defined. Following successful percutaneous coronary intervention (PCI) of the culprit lesion, immediate PCI of all additional lesions or staged PCI, after invasive or non-invasive proof of ischemia or conservative therapy can be considered. Randomized studies have demonstrated a clinical benefit of immediate or staged multivessel PCI compared to a conservative approach. So far there are no randomized studies available comparing immediate versus staged PCI. The data regarding the optimal strategy in patients with cardiogenic shock show low concordance. The currently running CULPRIT shock study will help to define the optimal strategy in shock patients. This manuscript summarizes the current knowledge and data and provides recommendations for the clinical practice.
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Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review. Cardiol Rev 2016; 25:179-188. [PMID: 27124268 DOI: 10.1097/crd.0000000000000110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.
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Bărcan A, Chițu M, Benedek E, Rat N, Korodi S, Morariu M, Kovacs I. Predictors of Mortality in Patients with ST-Segment Elevation Acute Myocardial Infarction and Resuscitated Out-of-Hospital Cardiac Arrest. ACTA ACUST UNITED AC 2016; 2:22-29. [PMID: 29967833 DOI: 10.1515/jccm-2016-0001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 12/15/2015] [Indexed: 11/15/2022]
Abstract
Introduction In patients with out-of-hospital cardiac arrest (OHCA) complicating an ST-segment elevation myocardial infarction (STEMI), the survival depends largely on the restoration of coronary flow in the infarct related artery. The aim of this study was to determine clinical and angiographic predictors of in-hospital mortality in patients with OHCA and STEMI, successfully resuscitated and undergoing primary percutaneous intervention (PCI). Methods From January 2013 to July 2015, 78 patients with STEMI presenting OHCA, successfully resuscitated, transferred immediately to the catheterization unit and treated with primary PCI, were analyzed. Clinical, laboratory and angiographic data were compared in 28 non-survivors and 50 survivors. Results The clinical baseline characteristics of the study population showed no significant differences between the survivors and non-survivors in respect to age (p=0.06), gender (p=0.8), the presence of hypertension (p=0.4), dyslipidemia (p=0.09) obesity (p=1), smoking status (p=0.2), presence of diabetes (p=0.2), a clinical history of acute myocardial infarction (p=0.7) or stroke (p=0.17). Compared to survivors, the non-survivor group exhibited a significantly higher incidence of cardiogenic shock (50% vs 24%, p=0.02), renal failure (64.3% vs 30.0%, p=0.004) and anaemia (35.7% vs 12.0%, p=0.02). Three-vessel disease was significantly higher in the non-survivor group (42.8% vs. 20.0%, p=0.03), while there was a significantly higher percentage of TIMI 3 flow postPCI in the infarct-related artery in the survivor group (80.% vs. 57.1%, p=0.03). The time from the onset of symptoms to revascularization was significantly higher in patients who died compared to those who survived (387.5 +/- 211.3 minutes vs 300.8 +/- 166.1 minutes, p=0.04), as was the time from the onset of cardiac arrest to revascularization (103.0 +/- 56.34 minutes vs 67.0 +/- 44.4 minutes, p=0.002). Multivariate analysis identified the presence of cardiogenic shock (odds ratio [OR]: 3.17, p=0.02), multivessel disease (OR: 3.0, p=0.03), renal failure (OR: 4.2, p=0.004), anaemia (OR: 4.07, p=0.02), need for mechanical ventilation >48 hours (OR: 8.07, p=0.0002) and a duration of stay in the ICU longer than 5 days (OR: 9.96, p=0.0002) as the most significant independent predictors for mortality in patients with OHCA and STEMI. Conclusion In patients surviving an OHCA in the early phase of a myocardial infarction, the presence of cardiogenic shock, renal failure, anaemia or multivessel disease, as well as a longer time from the onset of symptoms or of cardiac arrest to revascularization, are independent predictors of mortality. However, the most powerful predictor of death is the duration of stay in the ICU and the requirement of mechanical ventilation for more than forty-eight hours.
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Affiliation(s)
- Andreea Bărcan
- University of Medicine and Pharmacy of Tirgu Mureş, Tirgu Mures, Romania.,Department of Internal Medicine, Clinic of Cardiology, Tirgu Mures, Romania
| | - Monica Chițu
- University of Medicine and Pharmacy of Tirgu Mureş, Tirgu Mures, Romania.,Department of Internal Medicine, Clinic of Cardiology, Tirgu Mures, Romania
| | - Edvin Benedek
- University of Medicine and Pharmacy of Tirgu Mureş, Tirgu Mures, Romania.,Department of Internal Medicine, Clinic of Cardiology, Tirgu Mures, Romania
| | - Nora Rat
- University of Medicine and Pharmacy of Tirgu Mureş, Tirgu Mures, Romania.,Department of Internal Medicine, Clinic of Cardiology, Tirgu Mures, Romania
| | - Szilamer Korodi
- University of Medicine and Pharmacy of Tirgu Mureş, Tirgu Mures, Romania.,Department of Internal Medicine, Clinic of Cardiology, Tirgu Mures, Romania
| | - Mirabela Morariu
- University of Medicine and Pharmacy of Tirgu Mureş, Tirgu Mures, Romania.,Department of Internal Medicine, Clinic of Cardiology, Tirgu Mures, Romania
| | - Istvan Kovacs
- University of Medicine and Pharmacy of Tirgu Mureş, Tirgu Mures, Romania.,Department of Internal Medicine, Clinic of Cardiology, Tirgu Mures, Romania
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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. Am Heart J 2016; 172:160-9. [PMID: 26856228 DOI: 10.1016/j.ahj.2015.11.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/15/2015] [Indexed: 12/22/2022]
Abstract
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.
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Spence N, Abbott JD. Coronary Revascularization in Cardiogenic Shock. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 18:1. [DOI: 10.1007/s11936-015-0423-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Henry TD, Uberoi AM. Complete revascularisation or culprit artery only in cardiogenic shock: the real shock is the lack of data! Heart 2015; 101:1178-9. [PMID: 25987269 DOI: 10.1136/heartjnl-2015-307844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
Familial hypobetalipoproteinemia (FHBL), an autosomal dominant disorder, is defined as <5th percentile LDL-cholesterol or apolipoprotein (apo) B in the plasma. FHBL subjects are generally heterozygous and asymptomatic. Three genetic forms exist: (i) premature stop codon specifying mutations of APOB; (ii) FHBL linked to a susceptibility locus on the chromosome 3p21; and (iii) FHBL linked neither to APOB nor to the chromosome 3p21. In heterozygous apoB-defective FHBL, the hepatic VLDL export system is defective because apoB 100, the product of the normal allele, is produced at approximately 25% of normal rate, and truncated apoB is cleared too rapidly. The reduced capacity for hepatic triglyceride export increases hepatic fat three-fold. Indexes of adiposity and insulin action are similar to controls. 'Knock-in' mouse models of apoB truncations resemble human FHBL phenotypes. Liver fat in the chromosome 3p21-linked FHBL is normal. Elucidation of the genetic basis of the non-apoB FHBL could uncover attractive targets for lipid-lowering therapy. (See note added in proof.).
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Affiliation(s)
- G Schonfeld
- Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8046, St. Louis, Missouri 63110, USA.
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