Prognostic impact of non-culprit chronic total occlusions in infarct-related cardiogenic shock: results of the randomised IABP-SHOCK II trial

Optimal Heart Failure Medical Therapy and Mortality in Survivors of Cardiogenic Shock: Insights From the FRENSHOCK Registry

BACKGROUND

The effects of pharmacological therapy on cardiogenic shock (CS) survivors have not been extensively studied. Thus, this study investigated the association between guideline-directed heart failure (HF) medical therapy (GDMT) and one-year survival rate in patients who are post-CS.

METHODS AND RESULTS

FRENSHOCK (French Observatory on the Management of Cardiogenic Shock in 2016) registry was a prospective multicenter observational survey, conducted in metropolitan French intensive care units and intensive cardiac care units. Of 772 patients, 535 patients were enrolled in the present analysis following the exclusion of 217 in-hospital deaths and 20 patients with missing medical records. Patients with triple GDMT (beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists) at discharge (n=112) were likely to have lower left ventricular ejection fraction on admission and at discharge compared with those without triple GDMT (n=423) (22% versus 28%, P<0.001 and 29% versus 37%, P<0.001, respectively). In the overall cohort, the one-year mortality rate was 23%. Triple GDMT prescription was significantly associated with a lower one-year all-cause mortality compared with non-triple GDMT (adjusted hazard ratio 0.44 [95% CI, 0.19-0.80]; P=0.007). Similarly, 2:1 propensity score matching and inverse probability treatment weighting based on the propensity score demonstrated a lower incidence of one-year mortality in the triple GDMT group. As the number of HF drugs increased, a stepwise decrease in mortality was observed (log rank; P<0.001).

CONCLUSIONS

In survivors of CS, the one-year mortality rate was significantly lower in those with triple GDMT. Therefore, this study suggests that intensive HF therapy should be considered in patients following CS.

Long-Term Outcomes in Patients With Chronic Total Occlusion

Although a chronic total occlusion (CTO) in the setting of an acute coronary syndrome is associated with greater risk, the prognosis of patients with a CTO and stable coronary artery disease (CAD) remains unknown. This study aimed to investigate adverse event rates in patients with stable CAD with and without a CTO. In 3,597 patients with stable CAD (>50% coronary luminal stenosis) who underwent cardiac catheterization, all-cause mortality, cardiovascular mortality, and the composite major adverse cardiac event (MACE) rates for cardiovascular death, myocardial infarction, and heart failure hospitalization were evaluated. Cox proportional hazards and Fine and Gray subdistribution hazard models were used to compare event-free survival in patient subsets after adjustment for covariates. Event rates were higher in patients with CTOs than in those without CTOs after adjusting for demographic and clinical characteristics (cardiovascular death hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.05 to 1.57, p = 0.012). Patients with CTO revascularization had lower event rates than those of patients without CTO revascularization (cardiovascular death HR 0.43, CI 0.26 to 0.70, p = 0.001). Those with nonrevascularized CTOs were at particularly great risk when compared with those without CTO (cardiovascular death HR 1.52, CI 1.25 to 1.84, p <0.001). Moreover, those with revascularized CTOs had similar event rates to those of patients with CAD without CTOs. Patients with CTO have higher rates of adverse cardiovascular events than those of patients with significant CAD without CTO. This risk is greatest in patients with nonrevascularized CTO.

Trends and In-Hospital Outcomes of Patients Admitted with ST Elevation Myocardial Infarction and Chronic Total Occlusions: Insights from a National Database

Chronic total occlusion (CTO) is seen in a minority of ST-elevation myocardial infarction (STEMI) patients and is implicated in poor outcomes due to "double jeopardy". There is no large national data evaluating the trend and outcomes of STEMI patients who have a CTO (STEMI-CTO). We analyzed the Nationwide In-patients sample database from 2008-2011 and compared the trends, clinical characteristics, and in-hospital outcomes of STEMI patients with and without CTO. An increasing trend of CTO was seen in STEMI patients from 2008 to 2011. STEMI-CTO patients were younger, more likely develop cardiogenic shock, undergo percutaneous coronary intervention and thrombolysis. In this large, contemporary, national database, we also found that STEMI-CTO patients were more likely to have iatrogenic cardiac & vascular complications and undergo percutaneous mechanical circulatory support. We did not find significant difference in in-hospital deaths between STEMI-CTO patients and those without CTO.

Prognostic impact of non-culprit chronic total occlusion over time in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

AIMS

Previous studies indicated that a chronic total occlusion (CTO) in a non-infarct-related artery is linked to higher mortality mainly in the acute setting in patients with ST-elevation myocardial infarction (STEMI). Our aim was to assess the temporal distribution of mortality risk associated with non-culprit CTO over years after STEMI.

METHODS AND RESULTS

The study included 8679 STEMI patients treated with primary percutaneous coronary intervention (PCI). Kaplan-Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with log-rank test, with landmarks set at 30 days and 1 year. Adjusted Cox regression models were constructed to assess the impact of non-culprit CTO on mortality over different time intervals. Tests for interaction were pre-specified between non-culprit CTO and acute heart failure and left ventricular ejection fraction. The primary outcome variable was all-cause mortality, and the median follow-up was 5 years. Non-culprit CTO was present in 11.6% of patients (n = 1010). Presence of a CTO was associated with increased early [30-day adjusted hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.54-2.36; P < 0.001] and late mortality (5-year adjusted HR 1.66, 95% CI 1.42-1.95; P < 0.001). Landmark analyses revealed an annual two-fold increase in mortality in patients with vs. without a CTO after the first year of follow-up. The observed pattern of mortality increase over time was independent of acute or chronic LV impairment.

CONCLUSIONS

Non-culprit CTO is independently associated with mortality over 5 years after primary PCI for STEMI, with a constant annual two-fold increase in the risk of death beyond the first year of follow-up.

Impact of chronic total occlusion and revascularization strategy in patients with infarct-related cardiogenic shock: A subanalysis of the culprit-shock trial

BACKGROUND

The impact of coronary artery chronic total occlusion (CTO) and its management with percutaneous coronary intervention (PCI) in the setting of myocardial infarction (MI) related cardiogenic shock (CS) remains unclear.

METHODS

This is a pre-specified analysis from the culprit-lesion-only PCI vs multivessel PCI in CS (CULPRIT-SHOCK) trial which randomized patients presenting with MI and multivessel disease complicated by CS to a culprit-lesion-only or immediate multivessel PCI strategy. CTO was defined by central core-laboratory evaluation. The independent associations between the presence of CTO and adverse outcomes at 30 days and 1 year were assessed using multivariate logistics models.

RESULTS

A noninfarct related CTO was present in 157 of 667 (23.5%) analyzed patients. Patients presenting with CTO had more frequent diabetes mellitus or prior PCI but less frequently presented with ST segment elevation MI as index event. The presence of CTO was associated with higher rate of death at 30 days (adjusted Odds ratio 1.63; 95% confidence interval [CI] 1.01-2.60). Rate of death at 1 year was also increased but did not reach statistical significance (adjusted Odds ratio 1.62; 95%CI 0.99-2.66). Compare to immediate multivessel PCI, a strategy of culprit-lesion-only PCI was associated with lower rates of death or renal replacement therapy at 30 days in patients with and without CTO (Odds ratio 0.79 95%CI 0.42-1.49 and Odds ratio 0.67 95%CI 0.48-0.96, respectively), without significant interaction (P = .68).

CONCLUSIONS

In patients with MI-related CS and multivessel disease, the presence of CTO is associated with adverse outcomes while a strategy of culprit-lesion-only PCI seems beneficial regardless of the presence of CTO.

The long-term impact of a chronic total occlusion in a non-infarct-related artery on acute ST-segment elevation myocardial infarction after primary coronary intervention

OBJECTIVES

To investigate the long-term outcome of patients with acute ST-segment elevation myocardial infarction (STEMI) and a chronic total occlusion (CTO) in a non-infarct-related artery (IRA) and the risk factors for mortality.

METHODS

The enrolled cohort comprised 323 patients with STEMI and multivessel diseases (MVD) that received a primary percutaneous coronary intervention between January 2008 and November 2013. The patients were divided into two groups: the CTO group (n = 97) and the non-CTO group (n = 236). The long-term major adverse cardiovascular and cerebrovascular events (MACCE) experienced by each group were compared.

RESULTS

The rates of all-cause mortality and MACCE were significantly higher in the CTO group than they were in the non-CTO group. Cox regression analysis showed that an age ≥ 65 years (OR = 3.94, 95% CI: 1.47-10.56, P = 0.01), a CTO in a non-IRA(OR = 5.09, 95% CI: 1.79 ~ 14.54, P < 0.01), an in-hospital Killip class ≥ 3 (OR = 4.32, 95% CI: 1.71 ~ 10.95, P < 0.01), and the presence of renal insufficiency (OR = 5.32, 95% CI: 1.49 ~ 19.01, P = 0.01), stress ulcer with gastraintestinal bleeding (SUB) (OR = 6.36, 95% CI: (1.45 ~ 28.01, P = 0.01) were significantly related the 10-year mortality of patients with STEMI and MVD; an in-hospital Killip class ≥ 3 (OR = 2.97,95% CI:1.46 ~ 6.03, P < 0.01) and the presence of renal insufficiency (OR = 5.61, 95% CI: 1.19 ~ 26.39, P = 0.03) were significantly related to the 10-year mortality of patients with STEMI and a CTO.

CONCLUSIONS

The presence of a CTO in a non-IRA, an age ≥ 65 years, an in-hospital Killip class ≥ 3, and the presence of renal insufficiency, and SUB were independent risk predictors for the long-term mortality of patients with STEMI and MVD; an in-hospital Killip class ≥ 3 and renal insufficiency were independent risk predictors for the long-term mortality of patients with STEMI and a CTO.

Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction

Coronary chronic total occlusion (CTO) has gained increasing clinical attention as the most advanced form of coronary artery disease. Prior studies already indicated a clear association of CTO with adverse clinical outcomes, especially in patients with acute myocardial infarction (AMI) and concomitant CTO of the non-infarct-related coronary artery (non-IRA). Nevertheless, the prognostic impact of percutaneous coronary intervention (PCI) of CTO in the acute setting during AMI is still controversial. Due to the complexity of the CTO lesion, CTO-PCI leads to an increased risk of complications compared to non-occlusive coronary lesions. Therefore, this review outlines the prognostic impact of CTO-PCI in patients with AMI. In addition, the prognostic impact of periprocedural myocardial infarction caused by CTO-PCI will be discussed.

Impact of treatment strategies on long-term outcome of CTO patients

BACKGROUND

The percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains debated. Therefore the aim of this large-scale observational multi-center registry was to compare the long-term outcome of CTO patients undergoing different therapeutic approaches comparing successful CTO revascularization either by PCI or coronary artery bypass graft (CABG), failed CTO-PCI and optimal medical therapy (OMT) alone.

METHODS AND RESULTS

A total of 6630 CTO patients were enrolled from two high-volume centers to compare different treatment strategies. All procedures were performed by high-volume CTO operators in tertiary university hospital. Successful CTO-PCI was performed in 3906 patients, failed CTO-PCI in 1479 patients, 412 patients underwent CABG surgery and 833 patients were treated with OMT. During the 5-year follow-up period, 1019 (15%) patients died. Kaplan-Meier analysis unveiled a significantly improved long-term outcome for CTO patients undergoing revascularization either by PCI or by CABG compared to patients with failed CTO-PCI or OMT alone (log-rank P < 0.001). In the multivariate Cox-regression analysis successful CTO-PCI was associated with significantly improved long-term outcome compared to patients under OMT (adj. HR 0.39, 95%CI 0.33-0.45, P < 0.001) or CABG (adj. HR 0.68, 95%CI 0.53-0.86, P = 0.002) independent of clinical confounders encompassing age, BMI, diabetes, kidney function and left ventricular function.

CONCLUSIONS

This study showed an improved long-term outcome for CTO revascularization compared to optimal medical therapy, independent from revascularization mode, with the highest survival rate in patients undergoing successful CTO-PCI.

Temporary Mechanical Circulatory Support in Acute Heart Failure

Cardiogenic shock (CS) is a challenging syndrome, associated with significant morbidity and mortality. Although pharmacological therapies are successful and can successfully control this acute cardiac illness, some patients remain refractory to drugs. Therefore, a more aggressive treatment strategy is needed. Temporary mechanical circulatory support (TCS) can be used to stabilise patients with decompensated heart failure. In the last two decades, the increased use of TCS has led to several kinds of devices becoming available. However, indications for TCS and device selection are part of a complex process. It is necessary to evaluate the severity of CS, any early and prompt haemodynamic resuscitation, prior TCS, specific patient risk factors, technical limitations and adequacy of resources and training, as well as an assessment of whether care would be futile. This article examines options for commonly used TCS devices, including intra-aortic balloon pumps, a pulsatile percutaneous ventricular assist device (the iVAC), veno-arterial extra-corporeal membrane oxygenation and Impella (Abiomed) and TandemHeart (LivaNova) percutaneous ventricular assist device.

Contemporary prevalence, trends, and outcomes of coronary chronic total occlusions in acute myocardial infarction with cardiogenic shock

BACKGROUND

There are limited data on the prevalence and outcomes of chronic total occlusions (CTO) of the coronary artery in acute myocardial infarction with cardiogenic shock (AMI-CS) patients.

METHODS

Using the National Inpatient Sample, all admissions with AMI-CS that underwent diagnostic angiography between January 1, 2008, and December 31, 2014, were included. CTO, percutaneous coronary intervention (PCI), comorbidities and concomitant cardiac arrest was identified for all admissions. Outcomes of interest included temporal trends, in-hospital mortality, and resource utilization in cohorts with and without CTO.

RESULTS

In this 7-year period, 163,628 admissions with AMI-CS admissions met the inclusion criteria, with 68% being ST-elevation AMI-CS. CTO was noted in 27,343 (16.7%) admissions, with an increase in prevalence during the study period. The cohort with CTOs was more likely to be male and bearing private insurance. The CTO cohort had higher cardiovascular comorbidity, higher rates of cardiac arrest and higher use of PCI and mechanical circulatory support. The presence of a CTO was independently associated with higher in-hospital mortality (adjusted odds ratio 1.20 [95% confidence interval 1.16-1.23]; p < 0.001). The cohort with CTO had lower resource utilization (hospital stay and hospitalization costs) but was discharged more frequently to other hospitals. The presence of a CTO was associated with higher in-hospital mortality in the sub-groups of ST-elevation AMI-CS (31.5% vs. 28.7%; p < 0.001) and non-ST-elevation AMI-CS (24.8% vs. 23.2%; p < 0.001).

CONCLUSIONS

In this cohort of AMI-CS admissions that underwent diagnostic angiography, the presence of a CTO identified a higher risk cohort that had higher in-hospital mortality.

A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction

Patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the highest mortality rates recorded in critical care. Mortality rate in this setting is reported around 45-50% even in the most experienced and well-equipped medical centers. The continuous development of ST-segment elevation acute myocardial infarction (STEMI) networks has led not only to a dramatic decrease in STEMI-related mortality, but also to an increase in the frequency of severely complicated cases who survive to be transferred to tertiary centers for life-saving treatments. The reduced effectiveness of vasoactive drugs on a severely altered hemodynamic status led to the development of new devices dedicated to advanced cardiac support. What’s more, efforts are being made to reduce time from first medical contact to initiation of mechanical support in this particular clinical context. This review aims to summarize the most recent advances in mechanical support devices, in the setting of CS-complicated AMI. At the same time, the review presents several modern concepts in the organization of complex CS centers. These specialized hubs could improve survival in this critical condition.