ADP-receptor antagonists in patients with acute myocardial infarction complicated by cardiogenic shock: a pooled IABP-SHOCK II and CULPRIT-SHOCK trial sub-analysis

Purpose

The purpose of this pooled analysis is to compare the clinical outcome of patients with acute myocardial infarction complicated by cardiogenic shock treated with either clopidogrel or the newer, more potent ADP-receptor antagonists prasugrel or ticagrelor. Patients from the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) and Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial were included.

Methods and results

For the current analysis, the primary endpoint was 1-year mortality and the secondary safety endpoint was moderate or severe bleedings until hospital discharge with respect to three different ADP-receptor antagonists. Eight hundred fifty-six patients were eligible for analysis. Of these, five hundred seven patients (59.2%) received clopidogrel, one hundred seventy-eight patients (20.8%) prasugrel and one hundred seventy-one patients (20.0%) ticagrelor as acute antiplatelet therapy. The adjusted rate of mortality after 1-year did not differ between prasugrel and clopidogrel (hazard ratio [HR]: 0.81, 95% confidence interval [CI] 0.60–1.09, padj=0.17) or between ticagrelor and clopidogrel treated patients (HR: 0.86, 95% CI 0.65–1.15, padj=0.31). In-hospital bleeding events were significantly less frequent in patients treated with ticagrelor vs. clopidogrel (HR: 0.37, 95% CI 0.20–0.69, padj=0.002) and not different in patients treated with prasugrel vs. clopidogrel (HR: 0.73, 95% CI 0.43–1.24, padj=0.24), see Table 1.

Conclusion

This pooled sub-analysis is the largest analysis on safety and efficacy of three oral ADP-receptor antagonists and shows that an acute therapy with either clopidogrel, prasugrel or ticagrelor is no predictor of 1-year mortality. Treatment with ticagrelor seems to be associated with less in-hospital moderate and severe bleeding events in comparison to clopidogrel.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Heart FoundationEuropean Union 7th Framework Program

Impact of center-volume on outcomes in myocardial infarction complicated by cardiogenic shock – a CULPRIT-SHOCK sub-study

Background

Little is known about the impact of center-volume on outcomes in acute myocardial infarction complicated by cardiogenic shock (AMI-CS). The aim of this study was to investigate the association between center-volume, treatment strategies and subsequent outcome in patients with AMI-CS.

Methods

In this subanalysis of the randomized CULPRIT-SHOCK trial, study sites were categorized based on the annual volume of AMI-CS into low/intermediate/high volume centers (<50; 50–100;>100 cases/year). Subjects from the study/compulsory registry with available volume data were included. Baseline/procedural characteristics, overall treatment and 1-year all-cause mortality were compared across categories.

Results

N=1032 patients were included in this study (537 treated at low-volume, 240 at intermediate-volume and 255 at high volume centers). Baseline risk profile of patients across the volume categories was similar, although high volume centers included more older patients. Low/intermediate-volume centers had more resuscitated patients (57.5%/58.8% vs. 42.2%; p<0.01), and more patients on mechanical ventilation in comparison to high volume centers. Mechanical circulatory support differed with more use in low/intermediate-volume centers and overall lower use in high-volume centers (30.7%/36.7% vs. 19.2%; p<0.001). There were no differences in reperfusion success despite considerable differences in adjunctive pharmacological/device therapies (figure 1). There was no difference in 1-year all-cause mortality across volume categories (51.1% vs. 56.5% vs. 54.4%; p=0.34).

Conclusion

In this study of patients with AMI-CS, considerable differences in adjunctive medical and mechanical support therapies was observed. However, we could not detect an impact of center volume on reperfusion success or mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): The CULPRIT-SHOCK trial was funded by European Union, Seventh Framework Programme (FP7/2007-2013) Grant agreement n°602202, German Heart Research Foundation Treatment according to center volumeLong-term survival

Impact of left atrial diameter on outcome in patients undergoing edge-to-edge mitral valve repair: results from the German TRAnscatheter Mitral valve Interventions registry (TRAMI)

Background

Left atrium (LA) dimension is a marker of disease severity and outcome in primary and secondary mitral regurgitation. In transcatheter mitral valve repair LA enlargement might additionally impact on device handling and technical success through an altered anatomy and atrial annular dilatation.

Methods

Data from the multicenter German transcatheter mitral valve intervention registry “TRAMI” were used to analyse the association of baseline LA diameter by tertiles and efficacy, safety and long-term clinical outcome in patients undergoing edge-to-edge repair with the MitraClip.

Results

In 520 of 843 patients prospectively enrolled in TRAMI baseline LA diameter were reported (median [interquartile range] LA diameter in tertiles: 44 [40–46] mm, 51 [48–53] mm and 60 [55–66] mm). Larger LA diameters were significantly associated with secondary etiology of mitral regurgitation, lower ejection fraction, larger left ventricle, male sex and atrial fibrillation (all p<0.05). Technical success was not different across tertiles (96%, 95.4%, 98.4% respectively, p=0.43) as were major in-hospital cardiovascular and cerebral adverse events (mortality, myocardial infarction or stroke) (1.8%, 1.2% and 4.4%, p=0.11 across tertiles). However, 4-year mortality significantly increased with larger LA diameter (32.9%, 46.4% and 51.7% respectively, p<0.01), as did hospitalization in survivors (60%, 67.6% and 78.9% respectively, p<0.05). The association between LA diameter and all-cause mortality remained significant after multivariable adjustment including baseline left ventricular end-diastolic diameter.

Conclusion

LA enlargement is a strong and independent predictor of adverse long-term outcome in mitral regurgitation suggesting that timely transcatheter mitral valve repair may have the potential to modify outcome.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The TRAMI registry has been supported by proprietary means of IHF. Additional funding is provided by “Deutsche Herzstiftung” and a grant from Abbott Vascular.

Prognostic impact of active mechanical circulatory support in cardiogenic shock complicating acute myocardial infarction: results from the CULPRIT-SHOCK trial

Background

Active mechanical circulatory support (MCS) devices are increasingly used in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). However, data derived from randomized controlled trials on the efficacy and safety of these devices are still limited.

Purpose

To analyze the prognostic impact of active MCS devices in a large prospective contemporary cohort of patients with CS complicating AMI.

Methods

This is a predefined subanalysis of the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups; (1) use of at least one active MCS device, vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or need of renal replacement therapy at 30 days.

Results

Two hundred of 1055 (19%) patients received at least one active MCS device (n=112 Impella®; n=95 extracorporeal membrane oxygenation [ECMO]; n=6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared to those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p<0.001). All-cause mortality at 30 days and 1 year as well as bleeding rates were significantly higher in the active MCS group (all p<0.001). After multivariable adjustment the use of active MCS was significantly associated with the primary endpoint (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.7–5.9; p<0.001).

Conclusion

In the CULPRIT-SHOCK randomized trial and prospective registry approximately one fifth of patients was treated with active MCS devices. Compared to patients without active MCS, patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Supported by a grant (FP7/2007-2013) from the European Union 7th Framework Program and by the German Heart Research Foundation and the German Cardiac Society.

Impact of pre-hospital resuscitation on short-and long-term mortality in patients with cardiogenic shock and multivessel disease. Results of the CULPRIT trial

Background

There are only a few prospective data on the outcome of patients with cardio-pulmonary resuscitation (CPR) admitted with acute myocardial infarction (AMI) complicated by cardiogenic shock and an invasive strategy including primary percutaneous coronary intervention (PCI). Therefore, we evaluated the impact of pre-hospital CPR on outcomes in a large group of patients with AMI complicated by cardiogenic shock.

Methods

We used the data of the prospective CULPRIT-Shock trial and registry and including patients with acute myocardial infarction complicated by cardiogenic shock. The primary endpoint was 30-day mortality or renal replacement therapy.

Results

Between 2013 and 2017, a total of 1055 patients were included in the randomized trial (n=686) and in the registry (n=369), 550 (54%) had CPR, 40 had no information regarding CPR. Baseline characteristics, procedural features and outcomes in the two groups with and without CPR are given in the table.

Conclusion

Patients with pre-hospital CPR represent more than half of the population with AMI complicated by cardiogenic shock. They are younger, have less risk factors and more often LAD as infarct vessel. Despite the younger age and a high success rate of PCI patients with CPR have a high 30-day mortality.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum fuer Herz-Kreislauf-Forschung - DZHK

P5737Use of the IMPELLA mechanical support device in patients with acute myocardial infarction complicated by cardiogenic shock - Results of the CULPRIT-SHOCK trial

Background

Mortality in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is still high despite the use of early revascularization therapy. While IABP support has been shown not improve outcome more effective mechanical support devices such as the IMPELLA are increasingly used. We sought to study the use of the IMPELLA device in patients with multivessel coronary artery disease and CS.

Methods

The CULPRIT-SHOCK shock trial included 686 patients with AMI complicated by cardiogenic shock and multivessel coronary artery disease treated with early PCI. Patients were randomized to immediate multivessel PCI or culprit lesion only PCI. In the current subanalysis, we investigated the patients treated with an IMPELLA support device compared these to patients without IMPELLA.

Results

Of the 686 patients 82 (12%) were treated with an IMPELLA device, 32 (39%) with IMPELLA 2.5 and 50 (61%) with IMPELLA CP. The device has been implanted in 34 patients before and 48 patients after PCI. The table shows the baseline characteristics of the patients with and without IMPELLA. In an unadjusted analysis mortality was higher with IMPELLA (63% versus 45.5%). Patients with IMPELLA CP had somewhat lower mortality than IMPELLA 2.5 (59.2% versus 68.8%), while there was no difference for pre- and post-PCI implantation.

IMPELLA (n=82) No IMPELLA (n=606) p-value Age (years) 70 68 0.17 Women 22.2% 23.3% 0.88 Diabetes 37.7% 31.8% 0.30 Triple vessel disease 66.7% 62.9% 0.13 Left main disease 28.4% 14.1% 0.001 LV-EF 31% 34% 0.18 Lactate on admission 20 mmol/l 8 mmol/l 0.0001 Multivessel PCI 50.6% 51.1% 0.9 Mechanical ventilation 88.9% 80.2% 0.06 SAPS-2 score 65 55 0.0008

Conclusion

Currently the IMPELLA support device is used primarily in patients with higher risk indicated by a higher incidence of left main disease, higher lactate on admission and higher SAPS II scores. This is associated with a higher mortality. Therefore randomized trials are needed to determine the effect of IMPELLA on outcome in patients with cardiogenic shock.

P2268Incidence and prognostic impact of sepsis in patients with acute myocardial infarction complicated by cardiogenic shock - Results of the CULPRIT-SHOCK study and registry

Background

Patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) have a high mortality. It has been proposed that one component is a systemic inflammatory response to shock. Some of these patients even develop sepsis. Therefore,we analyzed a large cohort of patients with AMI and CS and sought to determine the incidence of sepsis and its impact on outcome.

Methods

The CULPRIT-SHOCKtrial and registry included 1009 patients with AMI complicated by CStreated with early PCI. In the trial 686 patients were randomized to immediate multivessel PCI or culprit lesion only PCI. In the current subanalysis patients were compared in those developing sepsis during the ICU phase to thosewithout sepsis.

Results

From the total of 1009 patients 103 (10%) developed sepsis. The baseline characteristics and 30-day outcomes are shown in the table.

Sepsis (n=103) No sepsis (n=906) p-value Age (yrs) 68 68 0.8 Women 22.3% 25.3% 0.5 Diabetes 34.3% 29.7% 0.3 GFR <60 ml/min 5.8% 6.4% 0.8 CPR 54.4% 54.2% 0.8 Lactat >5 mmol/l 54.2% 50.8% 0.6 Mechanical support device 35.0% 29.1% 0.2 Bleeding 28.2% 18.8% 0.02 Need for renal replacement therapy 37.9% 9.6% <0.0001 Mortality 54.4% 45.7% 0.08

Conclusion

About 10% of patients with AMI complicated by CSdevelop sepsis. Sepsis is associated with a higher incidence of the need for renal replacement therapy, bleeding and and a trend towards higher mortality. Therefore,further research is needed to improve outcome of these very high risk patients.

P1725Current spectrum and 1-year mortality of cardiogenic shock in Europe. Results of the CULPRIT-SHOCK randomized clinical trial and registry

Background

An early invasive strategy with coronary revascularization has been shown to improve prognosis in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Little is known about the current spectrum, treatment and 1-year mortality in patients with CS undergoing early angiography in Europe.

Methods

We evaluated baseline characteristics, treatments and 1-year outcome in a large number of patients with CS included into the prospective CULPRIT-SHOCK randomized trial and the accompanying registry. Between April 2013 and April 2017, a total of 1075 patients with cardiogenic shock were screened at 83 European centers, of whom 706 (65.6%) were included in the randomized trial RCTand 369 into the registry.

Results

The median age was 67 years and 25% were female. In total, 55% of patients had pre-hospital resuscitation, 6% underwent fibrinolysis before angiography, 65% presented with ST-elevation myocardial infarction, 15% with left bundle branch block, and 20% with non-ST-elevation myocardial infarction. The majority of patients (80%) needed mechanical ventilation. Catecholamines were used in 90% and mechanical support in 29.5% of the patients (IABP 38.5%, ECMO 22%, Impella 33%, other 7%). Total 30-day and 1-year mortality was 46% and 52%, respectively. Mechanical complications were observed in 2.1% of patients, the latter had a 30-day and 1-year mortality of 62% and 67%, respectively. The mortality related to the extent of coronary artery disease is shown in the table.

1-vessel (14%) 2-vessel (31%) 3-vessel (55%) Left main (15%) 30-day mortality 36% 44% 51% 53% 1-year mortality 39% 50% 57% 64%

Conclusions

This first report including data of the prospective CULPRIT-SHOCK randomized trial as well as the accompanying registry demonstrates the high-risk clinical characteristics of patients with AMI complicated by CS undergoing contemporary treatment. Despite an early invasive strategy mortality in patients with AMI complicated by CS in Europe is still high and is related to the extent of coronary artery disease.

P1724Prognostic impact of atrial fibrillation in acute myocardial infarction and cardiogenic shock: results from the CULPRIT-SHOCK trial

Background

It is unclear whether atrial fibrillation (AF) influences prognosis in patients with cardiogenic shock (CS) and multivessel disease.

Purpose

To investigate the prognostic impact of AF in patients with CS complicating acute myocardial infarction (AMI).

Methods

In a subanalysis of the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial, patients were grouped according to the presence of AF during index hospital stay. The primary endpoint was all-cause death at 30 days and the key secondary endpoint was all-cause death at 1 year.

Results

AF was documented in 142 (21%) of 686 patients. AF was not a significant predictor of 30-day (adjusted OR 1.01, 95% CI 0.66–1.56, p=0.95) and 1-year (adjusted OR 0.89, 95% CI 0.58–1.37, p=0.59) all-cause mortality. Patients with AF already on admission showed higher all-cause mortality at 30 days (52 of 90, 58% vs. 19 of 52, 37%; p=0.02) and 1 year (57 of 90, 63% vs. 20 of 52, 39%; p=0.004) compared to patients with newly detected AF during hospital stay. AF was significantly associated with the need for renal replacement therapy (adjusted OR 1.76, 95% CI 1.05–2.94, p=0.03) and longer time to hemodynamic stabilization (4, IQR 1–8 days vs. 3, IQR 1–6 days; p=0.04) at 30 days.

Conclusions

In CS complicating AMI all-cause mortality is similar in patients with and without AF. Adverse outcome was detected in the subgroup of patients showing AF already on hospital admission.

P4730Underweight is associated with unfavourable short- and long-term outcomes after MitraClip therapy: a body mass index derived subgroup analysis of the German Transcatheter Mitral Valve Interventions (

Background

Underweight and obesity represent classical risk factors for patients undergoing cardiac surgery or interventional treatment. The multicentre German Transcatheter Mitral Valve Interventions (TRAMI) registry comprises a large and prospectively enrolled real-world cohort of patients treated by MitraClip implantation.

Aims

The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy.

Methods and results

From 08/2010 until 07/2013, 799 patients (age 75.3±8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicentre, industry-independent German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into four groups: BMI<20 kg/m2 (underweight, n=49), BMI 20.0 to <25.0 kg/m2 (normal weight, n=293), BMI 25.0 to <30.0 kg/m2 (overweight, n=296) and BMI≥30 kg/m2 (obese, n=132). Procedure and radiation time were comparable among all groups. Significant increased rates of procedural failure (12.2% vs. 2.1 [normal weight], p<0.001), transfusion/bleeding (20.8% vs. normal weight: 5.6%, obesity: 7.0%, p<0.01), sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, p<0.01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine≥1.5mg/dl, diabetes, left ventricular ejection fraction<30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95%-confidence interval (CI): 1.01–2.46, p=0.044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55–0.93; p=0.011).

Conclusion

Underweight patients are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates when undergoing MitraClip implantation and should therefore be carefully discussed within the heart team.

Acknowledgement/Funding

The TRAMI registry has been supported by proprietary means of IHF. Additional funding is provided by “Deutsche Herzstiftung” and a grant from Abbott.