Multivessel Intervention in Myocardial Infarction with Cardiogenic Shock: CULPRIT-SHOCK Trial Outcomes in the PL-ACS Registry
Abstract
:1. Introduction
2. Materials and Methods
2.1. The PL-ACS Registry and Data Sources
2.2. The Design and Results of the CULPRIT-SHOCK Trial
2.3. Study Population
- Multivessel CAD defined as at least two major vessels (≥2 mm in diameter) with >70% stenosis of the diameter,
- An identifiable culprit lesion.
- No intrinsic heart action,
- Need for primary urgent coronary artery bypass grafting,
- Mechanical cause of CS,
- Massive pulmonary embolism,
- Age >90 years,
- Shock of other cause (bradycardia, sepsis, hypovolemia, etc.),
- Other known severe concomitant disease with limited life expectancy <6 months,
- Pregnancy,
- Known severe renal insufficiency (creatinine clearance <30 mL/kg).
2.4. Diagnostics and Treatment
2.5. Definitions and Outcome Measures
2.6. Statistical Analysis
3. Results
3.1. Identification of the CULPRIT-SHOCK-Like Cohort
3.2. Comparison of the CL-PCI versus the MV PCI
3.3. Comparison of the CL-PCI versus the MV PCI in the Matched Cohort
4. Discussion
4.1. CULPRIT-SHOCK Criteria
4.2. Strategies of Revascularization
4.3. Comparison of Treatment Outcomes Depending on Revascularization Strategy
4.4. Study Limitation
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Parameter | PL-ACS Population N = 1928 | PL-ACS Matched Cohort N = 1234 | ||||
---|---|---|---|---|---|---|
Culprit-Lesion-Only PCI n = 883 | Multivessel PCI n = 1045 | p | Culprit-Lesion-Only PCI n = 617 | Multivessel PCI n = 617 | p | |
Age, years, median (Q1–Q3) | 70 (62–78) | 69 (61–78) | 0.17 | 70 (62–78) | 69 (62–78) | 0.55 |
Male sex, n/N (%) | 535/883 (60.6) | 677/1045 (64.8) | 0.057 | 380/617 (61.6) | 397/617 (64.3) | 0.32 |
Weight, kg, median (Q1–Q3) | 80 (70–88) | 78 (70–88) | 0.37 | 80 (70–87) | 79 (70–87) | 0.37 |
Height, cm, median (Q1–Q3) | 170 (164–175) | 170 (164–175) | 0.37 | 170 (164–175) | 170 (164–175) | 0.42 |
BMI, kg/m2, median (Q1–Q3) | 27 (25–30) | 27 (24–29) | 0.069 | 27 (25–30) | 27 (25–30) | 0.063 |
Cardiovascular risk factors | ||||||
Current smoking, n/N (%) | 220/691 (31.8) | 256/946 (27.1) | 0.036 | 169/513 (32.9) | 153/543 (28.2) | 0.093 |
Arterial hypertension, n/N (%) | 506/789 (64.1) | 567/997 (56.9) | 0.0019 | 358/580 (61.7) | 358/580 (61.7) | >0.99 |
Hypercholesterolemia, n/N (%) | 289/753 (38.4) | 330/984 (33.5) | 0.037 | 198/565 (35.0) | 192/574 (33.4) | 0.57 |
Diabetes mellitus, n/N (%) | 284/800 (35.5) | 308/989 (31.1) | 0.051 | 192/584 (32.9) | 186/584 (31.8) | 0.71 |
Previous MI, n/N (%) | 185/805 (23.0) | 212/1007 (21.1) | 0.32 | 120/586 (20.5) | 117/593 (19.7) | 0.75 |
Previous PCI, n/N (%) | 105/810 (13.0) | 129/1009 (12.8) | 0.91 | 63/588 (10.7) | 69/595 (11.6) | 0.63 |
Previous CABG, n/N (%) | 48/818 (5.9) | 27/1007 (2.7) | 0.0006 | 20/591 (3.4) | 13/593 (2.2) | 0.21 |
Fibrinolysis before PCI | 1/544 (0.2) | 6/829 (0.7) | 0.32 | 1/452 (0.2) | 3/445 (0.7) | 0.60 |
Resuscitation before PCI, n/N (%) | 469/882 (53.2) | 416/1044 (39.8) | <0.0001 | 322/617 (52.2) | 322/617 (52.2) | >0.99 |
STEMI, n/N (%) | 637/883 (72.1) | 715/1045 (68.4) | 0.075 | 441/617 (71.5) | 429/617 (69.5) | 0.45 |
LBBB, n/N (%) | 59/881 (6.7) | 91/1044 (8.7) | 0.10 | 47/615 (7.6) | 57/617 (9.2) | 0.31 |
SBP, mmHg, median (Q1–Q3) | 89 (70–100) | 89 (70–105) | 0.84 | 90 (70–100) | 88 (70–100) | 0.92 |
DBP, mmHg, median (Q1–Q3) | 60 (40–67) | 60 (40–70) | 0.61 | 60 (40–65) | 60 (40–70) | 0.66 |
Heart rate, bpm, median (Q1–Q3) | 80 (65–100) | 88 (70–102) | 0.016 | 83 (70–105) | 85 (70–100) | 0.74 |
Creatinine, mg/dL, median (Q1–Q3) | 1.20 (0.94–1.52) | 1.25 (1.01–1.49) | 0.56 | 1.17 (0.92–151) | 1.29 (1.04–1.60) | 0.14 |
No. of affected vessels | ||||||
1, n/N (%) | - | - | - | - | ||
2, n/N (%) | 436/883 (49.4) | 505/1045 (48.3) | 0.65 | 299/617 (48.5) | 320/617 (51.9) | 0.23 |
3, n/N (%) | 447/883 (50.6) | 540/1045 (51.7) | 0.65 | 320/617 (51.9) | 299/617 (48.5) | 0.23 |
Vessel related to the infarction | ||||||
LM, n/N (%) | 67/883 (7.6) | 228/1045 (21.8) | <0.0001 | 65/617 (10.5) | 65/617 (10.5) | >0.99 |
LAD, n/N (%) | 353/883 (40.0) | 463/1045 (44.3) | 0.055 | 289/617 (46.8) | 289/617 (46.8) | >0.99 |
Cx, n/N (%) | 142/883 (16.1) | 149/1045 (14.3) | 0.27 | 91/617 (14.7) | 96/617 (15.6) | 0.69 |
RCA, n/N (%) | 305/883 (34.5) | 203/1045 (19.4) | <0.0001 | 165/617 (26.7) | 165/617 (26.7) | >0.99 |
Bypass graft, n/N (%) | 16/883 (1.8) | 2/1045 (0.2) | 0.0014 | 7/617 (1.1) | 2/617 (0.3) | 0.18 |
LVEF, n/N (%) | 35 (25–45) | 34 (25–41) | 0.051 | 35 (25–45) | 35 (25–43) | 0.45 |
Parameter | PL-ACS Population N = 1928 | PL-ACS Matched Cohort N = 1234 | ||||
---|---|---|---|---|---|---|
Culprit-Lesion-Only PCI n = 883 | Multivessel PCI n = 1045 | p | Culprit-Lesion-Only PCI n = 617 | Multivessel PCI n = 617 | p | |
Stent in culprit lesion | ||||||
Any, n/N (%) | 750/883 (84.9) | 929/1045 (88.9) | 0.0098 | 541/617 (87.7) | 545/617 (88.3) | 0.75 |
Drug eluting, n/N (%) | 454/750 (60.5) | 529/929 (56.9) | 0.14 | 296/541 (54.7) | 305/545 (56.0) | 0.68 |
TIMI grade for blood flow | ||||||
Before PCI of culprit lesion | ||||||
0, n/N (%) | 353/545 (64.8) | 446/844 (52.8) | 277/452 (61.3) | 277/452 (61.3) | ||
I, n/N (%) | 97/545 (17.8) | 169/844 (20.0) | 89/452 (19.7) | 89/452 (19.7) | ||
II, n/N (%) | 49/545 (9) | 126/844 (14.9) | 45/452 (10.0) | 45/452 (10.0) | ||
III, n/N (%) | 46/545 (8.4) | 103/844 (12.2) | <0.0001 | 41/452 (9.1) | 41/452 (9.1) | >0.99 |
After PCI of culprit lesion | ||||||
0, n/N (%) | 66/856 (7.7) | 61/1025 (6.0) | 43/602 (7.1) | 35/603 (5.8) | ||
I, n/N (%) | 45/856 (5.3) | 45/1025 (4.4) | 37/602 (6.1) | 33/603 (5.5) | ||
II, n/N (%) | 94/856 (11.0) | 77/1025 (7.5) | 67/602 (11.1) | 44/603 (7.3) | ||
III, n/N (%) | 651/856 (76.1) | 842/1025 (82.1) | 0.011 | 455/602 (75.6) | 491/603 (81.4) | 0.066 |
Staged PCI of nonculprit lesions, n/N (%) | 120/883 (13.6) | 44/1045 (4.2) | <0.0001 | 89/617 (14.4) | 31/617 (5.0) | <0.0001 |
Mechanical circulatory support, n/N (%) | 131/879 (14.9) | 204/1045 (19.5) | 0.0078 | 105/615 (17.1) | 119/617 (19.3) | 0.31 |
GP IIb/IIIa inhibitor, n/N (%) | 343/874 (39.2) | 468/1042 (44.9) | 0.012 | 242/613 (39.5) | 275/615 (44.7) | 0.063 |
Parameter | PL-ACS Population N = 1928 | PL-ACS Matched Cohort N = 1234 | ||||||
---|---|---|---|---|---|---|---|---|
Culprit-Lesion-Only PCI n = 883 | Multivessel PCI n = 1045 | Relative Risk (95% CI) | p | Culprit-Lesion-Only PCI n = 617 | Multivessel PCI n = 617 | Relative Risk (95% CI) | p | |
Outcomes at 30 days | ||||||||
Death from any cause, n/N (%) | 396/807 (49.1) | 554/1011 (54.8) | 0.90 (0.82–0.98) | 0.015 | 289/586 (49.3) | 337/591 (57.0) | 0.86 (0.58–0.92) | 0.0081 |
Recurrent myocardial infarction, n/N (%) | 9/248 (3.6) | 7/663 (1.1) | 3.44 (1.19–10.14) | 0.0085 | 6/192 (3.1) | 3/356 (0.8) | 3.80 (0.84–19.6) | 0.098 |
Rehospitalization for congestive heart failure, n/N (%) | 3/248 (1.2) | 6/663 (0.9) | 1.34 (0.27–5.94) | 0.68 | 3/192 (1.6) | 3/356 (0.8) | 1.87 (0.30–11.40) | 0.73 |
Staged or urgent repeat revascularization, n/N (%) | 39/248 (15.7) | 34/663 (5.1) | 3.07 (1.94–4.86) | <0.0001 | 33/192 (17.2) | 20/356 (5.6) | 3.06 (1.75–5.40) | <0.0001 |
Stroke, n/N (%) | 3/248 (1.2) | 5/663 (0.8) | 1.60 (0.31–7.61) | 0.51 | 3/192 (1.6) | 3/356 (0.8) | 1.87 (0.30–11.40) | 0.73 |
Outcomes at 12 months | ||||||||
Death from any cause, n/N (%) | 404/655 (61.7) | 592/896 (66.1) | 0.93 (0.86–1.01) | 0.075 | 320/512 (62.5) | 334/491 (68.0) | 0.92 (0.84–1.01) | 0.066 |
Recurrent myocardial infarction, n/N (%) | 19/229 (8.3) | 36/641 (5.6) | 1.48 (0.83–2.60) | 0.15 | 15/182 (8.2) | 18/338 (5.3) | 1.55 (0.76–3.15) | 0.19 |
Rehospitalization for congestive heart failure, n/N (%) | 14/229 (6.1) | 33/641 (5.1) | 1.20 (0.63–2.29) | 0.58 | 12/182 (6.6) | 21/338 (6.2) | 1.06 (0.50–2.20) | 0.87 |
Stroke, n/N (%) | 5/229 (2.2) | 14/641 (2.2) | 1.00 (0.32–2.93) | >0.99 | 4/182 (2.2) | 8/338 (2.4) | 0.93 (0.24–3.34) | 0.99 |
Repeat revascularization | ||||||||
Any, n/N (%) | 73/229 (31.9) | 91/641 (14.2) | 2.25 (1.69–2.96) | <0.0001 | 60/182 (33.0) | 49/338 (14.5) | 2.27 (1.61–3.22) | <0.0001 |
PCI, n/N (%) | 58/229 (25.3) | 80/641 (12.5) | 2.03 (1.48–2.77) | <0.0001 | 49/182 (26.9) | 43/338 (12.7) | 2.12 (1.44–3.12) | <0.0001 |
CABG, n/N (%) | 16/229 (7.0) | 13/641 (2.0) | 3.45 (1.60–7.49) | <0.0001 | 12/182 (6.6) | 7/338 (2.1) | 3.18 (1.19–8.83) | 0.0040 |
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Gąsior, M.; Desperak, P.; Dudek, D.; Witkowski, A.; Buszman, P.E.; Trzeciak, P.; Hawranek, M.; Gierlotka, M.; Bartuś, S.; Grygier, M.; et al. Multivessel Intervention in Myocardial Infarction with Cardiogenic Shock: CULPRIT-SHOCK Trial Outcomes in the PL-ACS Registry. J. Clin. Med. 2021, 10, 1832. https://doi.org/10.3390/jcm10091832
Gąsior M, Desperak P, Dudek D, Witkowski A, Buszman PE, Trzeciak P, Hawranek M, Gierlotka M, Bartuś S, Grygier M, et al. Multivessel Intervention in Myocardial Infarction with Cardiogenic Shock: CULPRIT-SHOCK Trial Outcomes in the PL-ACS Registry. Journal of Clinical Medicine. 2021; 10(9):1832. https://doi.org/10.3390/jcm10091832
Chicago/Turabian StyleGąsior, Mariusz, Piotr Desperak, Dariusz Dudek, Adam Witkowski, Paweł E. Buszman, Przemysław Trzeciak, Michał Hawranek, Marek Gierlotka, Stanisław Bartuś, Marek Grygier, and et al. 2021. "Multivessel Intervention in Myocardial Infarction with Cardiogenic Shock: CULPRIT-SHOCK Trial Outcomes in the PL-ACS Registry" Journal of Clinical Medicine 10, no. 9: 1832. https://doi.org/10.3390/jcm10091832