P2732Revascularization in patients with acute myocardial infarction and cardiogenic shock - Results from a national registry

Abstract

Background: In patients with acute myocardial infarction (MI) and cardiogenic shock (CS), revascularization of the culprit artery improves prognosis. However, a significant proportion of patients presents with multivessel disease (MVD). Although the guidelines recommend complete revascularization during the index procedure, recent data challenges this strategy. Purpose: To compare different revascularization strategies in patients with AMI and CS. Methods: We included patients with acute MI and CS from the Portuguese Registry on Acute Coronary Syndromes (PRACS), and compared three revascularization strategies during hospitalization (complete revascularization in the index procedure - group 1, complete staged revascularization - group 2, and incomplete revascularization - group 3). The primary endpoint was a composite of inhospital death or MI. Results: Among the 17.834 patients included between 2010 and 2017, 329 presented with acute MI and CS (1.8%). After excluding patients with incomplete information, not revascularized or that underwent fibrinolysis and delayed percutaneous coronary intervention (PCI), 222 patients were included (50.0% in group 1, 4.1% in group 2, and 45.9% in group 3). Most patients were male (65.8%), with a mean age of 67±14 years. 92.3% had a diagnosis of STEMI, and 32.1% were admitted to non-PCI centers. The culprit artery was the LAD in 36.3%, the RCA in 35.8% and 64.1% of patients had MVD. Intra-aortic balloon pump was used in 15.8% of patients, and left ventricular assist device in 0.5%. The primary endpoint occurred in 36.9% of patients, and in-hospital mortality was 34.2%. Comparing with patients in group 3, patients in groups 1-2 were younger (63±14 vs. 73±11 years), had a higher prevalence of smoking habits (40.5 vs. 18.4%), a lower prevalence of previous stroke (5.0 vs. 17.8%), and lower baseline creatinine (1.3 vs. 1.6 mg/dl). The primary endpoint occurred in 35.8% of the patients in groups 1-2 and 38.2% in group 3 (p=0.712). The rates of in-hospital mortality, stroke, and major bleeding were similar between groups, while there was a higher rate of recurrent acute MI in patients in groups 1-2 (5.0 vs. 0.0%; p=0.032). In logistic regression analysis, the predictors of in-hospital mortality in this population were the presence of RBBB on admission (OR 6.07) and LV systolic dysfunction (OR 15.82), while therapy with beta-blockers and ACE inhibitors during hospitalization had a protective effect (OR 0.02 and 0.15 respectively). Conclusions: Among patients with acute MI and CS included in the PRACS, there was no significant difference between complete and incomplete revascularization during the index hospitalization regarding the occurrence of the composite of in-hospital death or myocardial infarction. In this population the predictors of inhospital mortality were RBBB, LV systolic dysfunction and the absence of therapy with beta-blockers and ACE inhibitors.