P2731Complete or culprit only revascularization in patients with multivessel disease presenting with cardiogenic shock: a meta-analysis of RCT and adjusted observational results

Abstract

Introduction: Benefit of complete revascularization in patients with myocardial infarction (MI) presenting with cardiogenic shock (CS) remains to be elucidated. Methods: All studies (RCT; randomized controlled trial or observational with multivariate analysis) evaluating the impact of MV-PCI (MultiVessel-Percutaneous Coronary Intervention) vs. C-PCI (Culprit-Percutaneous Coronary Intervention) in patients with MI and CS were included. In hospital mortality at multivariate analysis was the primary end point, while in hospital mortality at univariate analysis, major bleeding and renal failure, long term mortality at univariate and multivariate analysis the secondary ones. At meta regression analysis, impact of clinical presentation (NSTEMI), of number of diseased vessels, of area of MI and of dialysis after PCI was evaluated on primary end point. Results: 11 studies, one RCT and 10 observational studies with multivariate adjustement were included, with 1549 patients treated with MV-PCI and 5209 with C-PCI. At univariate analysis, only a not significant trend against MV-PCI group emerged for short term death (OR 1.24, 95% CI 0.98-1.58, p=0.08). Multivariate adjustment did not confirmed this trend (OR 0.92,95% CI 0.64-1.32, p=0.64), while meta-regression analysis showed increased benefit for C-PCI in shocked patients needing dialysis (beta -0.027, 95% CI from -0.057 to -0.001; p 0.016; fig. 8), and on the contrary benefit of MV-PCI in anterior MI (beta 0.035, 95% CI from 0.003 to 0.066; p 0.0030). MV-PCI increased incidence of AKI (OR 1.36, 95% CI 1.06-1.75,p=0.02), while for long term survival MV-PCI and C-PCI appeared similar both at univariate as well as in the multivariate pooled analysis ([OR 0.99, 95% CI 0.65-1.52, p=0.97] and [OR 1.16, 95% CI 0.53-2.52, p=0.71] respectively). Conclusion: MV-PCI in MI patients presenting with cardiogenic shock appears more favorable for anterior MI, while its efficacy is limited by relevant risk of renal failure.