Comparison of Long-Term Clinical Outcome Between Multivessel Percutaneous Coronary Intervention Versus Infarct-Related Artery-Only Revascularization for Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock

Infarct-related artery only revascularization versus multi-vessel revascularization for patients with Killip I-IV acute myocardial infarction and multivessel disease

BACKGROUND

The optimal revascularization strategy for non-culprit vessels is still up for debate nowadays, particularly when it comes to individuals with different Killip classes. Therefore, the aim of our study was to investigate whether multivessel revascularization, as compared with infarct-related artery (IRA) alone revascularization, improves long-term prognosis in patients who have experienced an acute myocardial infarction (AMI) and have multivessel coronary artery disease (CAD).

METHODS

A retrospective analysis was conducted on clinical data from 646 patients who presented with AMI and multivessel CAD at Beijing Chaoyang hospital between November 2014 and November 2020. Based on various revascularization strategies, patients were categorised into two groups: IRA-only revascularization (n = 416) and multivessel revascularization (n = 230). The primary endpoint was cardiovascular death.

RESULTS

In the following 60.6 months (60.6 ± 23.9), the primary endpoint occurred in 3% of the multivessel revascularization group versus 9.6% in the IRA-only revascularization group (HR 0.284, CI 0.120-0.669, p = 0.002). For the Killip I-II patients (n = 533), the primary endpoint occurred in 2.6% of the multivessel revascularization group versus 9.5% in the IRA-only revascularization group (HR 0.236, CI 0.083-0.667, p = 0.003). For Killip III-IV patients (n = 113), there was no significance differences in the primary endpoint. After using the inverse probability weighted method, the benefit of complete revascularization was consistently observed.

CONCLUSIONS

Multivessel revascularization significantly reduced the incidence of cardiovascular death for patients presenting with AMI and multivessel CAD, particularly for Killip I-II patients. There were no significant differences in the primary outcome across the groups of patients with Killip III-IV.

Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction-What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention?

Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.

Renal Impact of Culprit-Only versus Multi-Vessel Revascularization for Cardiogenic Shock Complicating Acute Myocardial Infarction: Systematic Review and Meta-Analysis

Background

The optimal strategy of percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) complicated with cardiogenic shock (CS) remains controversial. We aimed to elucidate the renal and cardiovascular impact of culprit-only (C) revascularization versus additional interventions on non-infarct-related arteries.

Methods

PubMed, Embase, MEDLINE, and Cochrane Library were searched for relevant literature. A total of 96,812 subjects [C-PCI: 69,986; multi-vessel (MV)-PCI: 26,826] in nine studies (one randomized control trial; eight observational cohort studies) were enrolled.

Results

MV-PCI was associated with a higher kidney event rate [relative risk (RR): 1.29, 95% confidence interval (CI): 1.12-1.49; p < 0.001]. However, the all-cause mortality rate was comparable both during admission (RR: 1.07, 95% CI: 0.94-1.22; p = 0.30) and at one year (RR: 0.96, 95% CI: 0.79-1.16; p = 0.65). MV-PCI was associated with a greater risk of stroke (RR: 1.19, 95% CI: 1.08-1.32; p < 0.001) and bleeding events (RR: 1.27, 95% CI: 1.07-1.51; p = 0.006), but reduced risk of recurrent MI (RR: 0.89, 95% CI: 0.82-0.97; p = 0.009) and repeat revascularization (RR: 0.34, 95% CI: 0.16-0.71; p = 0.004). No increased risk of coronary artery bypass grafting was present (RR: 1.09, 95% CI: 0.38-3.17; p = 0.87).

Conclusions

C-PCI was associated with a lower rate of renal dysfunction but not all-cause mortality in patients with CS complicating acute MI.

Contemporary Management of Cardiogenic Shock Complicating Acute Myocardial Infarction

Despite an improvement in pharmacological therapies and mechanical reperfusion, the outcome of patients with acute myocardial infarction (AMI) is still suboptimal, especially in patients with cardiogenic shock (CS). The incidence of CS accounts for 3-15% of AMI cases, with mortality rates of 40% to 50%. In contrast to a large number of trials conducted in patients with AMI without CS, there is limited evidence-based scientific knowledge in the CS setting. Therefore, recommendations and actual treatments are often based on registry data. Similarly, knowledge of the available options in terms of temporary mechanical circulatory support (MCS) devices is not equally widespread, leading to an underutilisation or even overutilisation in different regions/countries of these treatment options and nonuniformity in the management of CS. The aim of this article is to provide a critical overview of the available literature on the management of CS as a complication of AMI, summarising the most recent evidence on revascularisation strategies, pharmacological treatments and MCS use.

When to Achieve Complete Revascularization in Infarct-Related Cardiogenic Shock

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encountered in patients with multivessel coronary artery disease (CAD). Despite prompt revascularization, in particular, percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for patients with CS related to AMI remains unacceptably high. Differently form a hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested for AMI–CS patients, based on the results of recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have emerged as a key therapeutic option in CS, especially in the case of their early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of the current evidence on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of different types of MCS devices and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

Clinical Nursing Pathway Improves Therapeutic Efficacy and Quality of Life of Elderly Patients with Acute Myocardial Infarction

Purposes

To clarify the impacts of clinical nursing pathway (CNP) on therapeutic efficacy and quality of life (QOL) of senile acute myocardial infarction (AMI) patients.

Methods

The clinical records of 177 elderly AMI patients who received treatment in the First Hospital of Quanzhou Affiliated to Fujian Medical University were retrospectively studied. They were assigned into the control group (the Con; n = 79; from June 2019 to January 2020) and the research group (the Res; n = 98; from February 2020 to July 2020). Emergency percutaneous coronary intervention (PCI) was performed in all the cases. Additionally, the Con and the Res were given routine care and CNP, respectively. The two groups were compared in total emergency treatment time, hospital stay, medical expenses, recurrence rate of myocardial infarction (MI), overall response rate (ORR), incidence of complications, cardiac function indexes, negative mood scores, QOL, and nursing satisfaction.

Results

The ORR was higher, and the incidence of complications was lower in the Res versus the Con; the Res presented significantly less emergency treatment time and hospitalization and statistically lower medical expenses and recurrence rate of MI; the Res outperformed the Con in cardiac function indexes, alleviation of negative mood, QOL, and nursing satisfaction.

Conclusions

While effectively improving clinical efficacy and reducing the incidence of complications, CNP can relieve the bad mood of elderly patients with AMI and improve their cardiac function, QOL, and nursing satisfaction, which is worthy of clinical promotion.

In-Hospital Mortality Risk Factor Analysis in Multivessel Percutaneous Coronary Intervention Inpatient Recipients in the United States

Objectives

The primary goal of our study is to evaluate the mortality rate in inpatient recipients of multivessel percutaneous coronary intervention (MVPCI) and to evaluate the demographic risk factors and medical complications that increase the risk of in-hospital mortality.

Methods

We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS, 2016) and included 127,145 inpatients who received MVPCI as a primary procedure in United States' hospitals. We used a multivariable logistic regression model adjusted for demographic confounders to measure the odds ratio (OR) of association of medical complications and in-hospital mortality risk in MVPCI recipients.

Results

The in-hospital mortality rate was 2% in MVPCI recipients and was seen majorly in older-age adults (>64 years, 74%) and males (61%). Even though the prevalence of mortality among females was comparatively low, yet in the regression model, they were at a higher risk for in-hospital mortality than males (OR 1.2; 95% CI 1.13-1.37). While comparing ethnicities, in-hospital mortality was prevalent in whites (79%) followed by blacks (9%) and Hispanics (7.5%). Patients who developed cardiogenic shock were at higher odds of in-hospital mortality (OR 9.2; 95% CI 8.27-10.24) followed by respiratory failure (OR 5.9; 95% CI 5.39-6.64) and ventricular fibrillation (OR 3.5; 95% CI 3.18-3.92).

Conclusion

Accelerated use of MVPCI made it important to study in-hospital mortality risk factors allowing us to devise strategies to improve the utilization and improve the quality of life of these at-risk patients. Despite its effectiveness and comparatively lower mortality profile, aggressive usage of MVPCI is restricted due to the periprocedural complications and morbidity profile of the patients.

Interventional Radiology ex-machina: impact of Artificial Intelligence on practice

Artificial intelligence (AI) is a branch of Informatics that uses algorithms to tirelessly process data, understand its meaning and provide the desired outcome, continuously redefining its logic. AI was mainly introduced via artificial neural networks, developed in the early 1950s, and with its evolution into "computational learning models." Machine Learning analyzes and extracts features in larger data after exposure to examples; Deep Learning uses neural networks in order to extract meaningful patterns from imaging data, even deciphering that which would otherwise be beyond human perception. Thus, AI has the potential to revolutionize the healthcare systems and clinical practice of doctors all over the world. This is especially true for radiologists, who are integral to diagnostic medicine, helping to customize treatments and triage resources with maximum effectiveness. Related in spirit to Artificial intelligence are Augmented Reality, mixed reality, or Virtual Reality, which are able to enhance accuracy of minimally invasive treatments in image guided therapies by Interventional Radiologists. The potential applications of AI in IR go beyond computer vision and diagnosis, to include screening and modeling of patient selection, predictive tools for treatment planning and navigation, and training tools. Although no new technology is widely embraced, AI may provide opportunities to enhance radiology service and improve patient care, if studied, validated, and applied appropriately.

Does multivessel revascularization fit all patients with STEMI and multivessel coronary artery disease? A systematic review and meta-analysis

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.

Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association

Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.

2021 Korean Society of Myocardial Infarction Expert Consensus Document on Revascularization for Acute Myocardial Infarction

Acute myocardial infarction (AMI) is a fatal manifestation of ischemic heart disease and remains a major public health concern worldwide despite advances in its diagnosis and management. The characteristics of patients with AMI, as well as its disease patterns, have gradually changed over time in Korea, and the outcomes of revascularization have improved dramatically. Several characteristics associated with the revascularization of Korean patients differ from those of patients in other countries. The sophisticated state of AMI revascularization in Korea has led to the need for a Korean expert consensus. The Task Force on Expert Consensus Document of the Korean Society of Myocardial Infarction has comprehensively reviewed the outcomes of large clinical trials and current practical guidelines, as well as studies on Korean patients with AMI. Based on these comprehensive reviews, the members of the task force summarize the major guidelines and recent publications, and propose an expert consensus for revascularization in patients with AMI.

Fibrinogen-to-albumin ratio predicts long-term outcomes for patients with ST-elevation myocardial infarction and multivessel disease: A prospective observational cohort study

The fibrinogen-to-albumin ratio index (FAR) is a valuable tool reflecting the systemic inflammation level and associated with the severity of coronary artery disease. However, the utility of the FAR in predicting the long-term prognosis of patients with ST-elevation myocardial infarction (STEMI) and multivessel disease has remained to be determined. A total of 424 patients diagnosed with STEMI and multivessel disease were recruited for the present study. They were given emergent percutaneous coronary intervention treatment and then completed a follow-up for primary (all-cause mortality) and secondary endpoints (major adverse cardiac events, including MI, stroke, emergent revascularization and rehospitalization due to heart failure). The association between FAR and the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score was investigated, while receiver operating characteristic curve analysis was adopted to assess the ability of the FAR to predict long-term outcomes. The long-term survival of high and low FAR groups was compared by drawing Kaplan-Meier survival curves. Multivariate Cox regression analysis was adopted to evaluate the risk factors of primary and secondary endpoints. The FAR was revealed to have a linear correlation with the SYNTAX score (y=0.022x+17.737; P=0.015). Furthermore, the FAR was a significant predictor of all-cause death with a cut-off value of 128.4 (area under the curve, 0.832; P<0.001). A significant difference was determined between the high FAR group and the low FAR group in terms of the proportion of patients with the primary endpoint (P<0.001) and secondary endpoint (P=0.001). It was demonstrated that the FAR was an independent risk factor for all-cause death of patients with STEMI and multivessel disease (hazard ratio, 1.029; 95% CI: 1.020-1.037; P<0.001). In summary, the FAR is a valuable biomarker associated with STEMI and may be useful in the prediction of the long-term prognosis of patients with STEMI and multivessel disease.

Practical guidance for P2Y12 inhibitors in acute myocardial infarction undergoing percutaneous coronary intervention

AIMS

Potent P2Y12 inhibitors for dual antiplatelet therapy (DAPT) is crucial for managing acute myocardial infarction; however, the selection of drugs is based on limited clinical information such as age and body weight. The current study sought to develop and validate a new risk scoring system that can be used to guide the selection of potent P2Y12 inhibitors by balancing ischaemic benefit and bleeding risk.

METHODS AND RESULTS

Derivation cohort of 10 687 patients who participated in the Korea Acute Myocardial Infarction Registry-National Institutes of Health study was used to construct a new scoring system. We combined the ischaemic and bleeding models to establish a simple clinical prediction score. Among the low score group (n = 1764), the observed bleeding risk (8.7% vs. 4.4%, P < 0.001) due to potent P2Y12 inhibitors exceeded ischaemic benefit (1.3% vs. 2.2%, P = 0.185) during 12 months. Conversely, the high score group (n = 1898) showed an overall benefit from taking potent P2Y12 inhibitors from the standpoint of observed ischaemic (17.1% vs. 8.6%, P < 0.001) and bleeding events (10.1% vs. 6.8%, P = 0.073). The performance of ischaemic [integrated area under the curve (iAUC) = 0.809] and bleeding model (iAUC = 0.655) was deemed to be acceptable.

CONCLUSION

The new scoring system is a useful clinical tool for guiding DAPT by balancing ischaemic benefit and bleeding risk, especially among Asian populations. Further validation studies with other cohorts will be required to verify that the new system meets the needs of real clinical practice.

Comparison of Long-Term Clinical Outcome Between Multivessel Percutaneous Coronary Intervention Versus Infarct-Related Artery-Only Revascularization for Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock

Background

Data are limited regarding long‐term outcomes in patients with ST‐segment–elevation myocardial infarction and multivessel disease presenting with cardiogenic shock according to revascularization strategy. We sought to compare the 3‐year clinical outcomes of patients with ST‐segment‐elevation myocardial infarction multivessel disease with cardiogenic shock and patients with multivessel percutaneous coronary intervention (PCI) and infarct‐related artery (IRA)–only PCI.

Methods and Results

Of 13 104 patients from the nationwide, multicenter, prospective KAMIR‐NIH (Korea Acute Myocardial Infarction Registry––National Institutes of Health) registry, we selected 659 patients with ST‐segment‐elevation myocardial infarction who had concomitant non‐IRA stenosis and presented with cardiogenic shock. The primary outcome was all‐cause death. Multivessel PCI was performed in 260 patients and IRA‐only PCI in 399 patients. At 3 years, patients in the multivessel PCI group had a lower risk of all‐cause death (adjusted hazard ratio, 0.65; 95% CI, 0.45–0.94 [P=0.024]), all‐cause death or MI (adjusted hazard ratio, 0.59; 95% CI, 0.41–0.84 [P=0.004]), and non‐IRA repeat revascularization (adjusted hazard ratio, 0.23; 95% CI, 0.10–0.50 [P<0.001]) than those in the IRA‐only PCI group. The results were consistent after confounder adjustment by propensity score matching and inverse probability weighting analysis. Landmark analysis at 1 year demonstrated that the multivessel PCI group had a lower risk of recurrent MI and non‐IRA repeat revascularization beyond 1 year (log‐rank P=0.030 and P=0.017, respectively) than the IRA‐only PCI group.

Conclusions

In patients with ST‐segment‐elevation myocardial infarction and cardiogenic shock, multivessel PCI was associated with a lower risk of all‐cause death than IRA‐only PCI at 3 years, suggesting potential benefit of non‐IRA revascularization during the index hospitalization to improve long‐term clinical outcomes.