Advertisement

Clinical Outcomes According to ECG Presentations in Infarct-Related Cardiogenic Shock in the Culprit Lesion Only PCI vs Multivessel PCI in Cardiogenic Shock Trial

Published:November 25, 2020DOI:https://doi.org/10.1016/j.chest.2020.10.089

      Background

      The impact of ECG presentations of acute myocardial infarction (AMI) in cardiogenic shock is unknown.

      Research Question

      In myocardial infarction with cardiogenic shock, is there a difference in the outcomes and effect of revascularization strategies between non-ST-segment elevation myocardial infarction (NSTEMI) and left bundle branch block myocardial infarction (LBBBMI) vs ST-segment elevation myocardial infarction (STEMI)?

      Study Design and Methods

      Cardiogenic shock patients from the CULPRIT-SHOCK trial with NSTEMI or LBBBMI were compared with STEMI patients for 30-day and 1-year all-cause mortality. The interaction between ECG presentation and the effect of revascularization strategies on outcomes was evaluated.

      Results

      Of 665 cardiogenic shock patients analyzed, 55.9% demonstrated STEMI, 29.3% demonstrated NSTEMI, and 14.7% demonstrated LBBBMI. Patients differed in mean age (68.0 years in STEMI patients, 71.0 years in NSTEMI patients, and 73.5 years in LBBBMI patients; P = .015), cardiovascular risk factors, and angiographic severity. No difference was found in the 30-day risk of death between NSTEMI and STEMI patients (48.7% vs 43.0%; adjusted OR [aOR], 1.05; 95% CI, 0.66-1.67; P = .85), nor between LBBBMI and STEMI patients (59.2% vs 43.0%; aOR, 1.31; 95% CI, 0.73-2.34; P = .36). Although the univariate risk of death by 1 year was higher in NSTEMI and LBBBMI patients compared with STEMI patients, ECG presentation was not an independent risk factor of mortality after adjustment (NSTEMI vs STEMI: 56.4% vs 46.8%; aOR, 1.21; 95% CI, 0.76-1.92; P = .42; LBBBMI vs STEMI: 69.4% vs 46.8%; aOR, 1.59; 95% CI, 0.89-2.84; P = .12). ECG presentation did not modify the effect of the revascularization strategy on 30-day and 1-year mortality (P = .91 and P = .97 for interaction).

      Interpretation

      In patients with cardiogenic shock, NSTEMI and LBBBMI presentations reflect higher-risk profiles than STEMI presentations, but are not independent risk factors of mortality. ECG presentations did not modify the treatment effect, supporting culprit-lesion-only percutaneous coronary intervention as the preferred strategy across the AMI spectrum.

      Key Words

      Abbreviations:

      AMI (acute myocardial infarction), aOR (adjusted OR), CULPRIT-SHOCK (Culprit Lesion Only PCI vs Multivessel PCI in Cardiogenic Shock), LBBB (left bundle branch block), LBBBMI (left bundle branch block myocardial infarction), NSTEMI (non-ST-segment elevation myocardial infarction), PCI (percutaneous coronary intervention), STEMI (ST-segment elevation myocardial infarction)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hollenberg S.M.
        • Kavinsky C.J.
        • Parrillo J.E.
        Cardiogenic shock.
        Ann Intern Med. 1999; 131: 47-59
        • Granger C.B.
        • Bates E.R.
        • Jollis J.G.
        • et al.
        Improving care of STEMI in the United States 2008 to 2012.
        J Am Heart Assoc. 2019; 8e008096
        • Holmes D.R.
        • Berger P.B.
        • Hochman J.S.
        • et al.
        Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation.
        Circulation. 1999; 100: 2067-2073
        • Anderson M.L.
        • Peterson E.D.
        • Peng S.A.
        • et al.
        Differences in the profile, treatment, and prognosis of patients with cardiogenic shock by myocardial infarction classification.
        Circ Cardiovasc Qual Outcomes. 2013; 6: 708-715
        • Berger P.B.
        • Tuttle R.H.
        • Holmes D.R.
        • et al.
        One-year survival among patients with acute myocardial infarction complicated by cardiogenic shock, and its relation to early revascularization: results from the GUSTO-I trial.
        Circulation. 1999; 99: 873-878
        • Webb J.G.
        • Sanborn T.A.
        • Sleeper L.A.
        • et al.
        Percutaneous coronary intervention for cardiogenic shock in the SHOCK Trial Registry.
        Am Heart J. 2001; 141: 964-970
        • Hochman J.S.
        • Sleeper L.A.
        • Webb J.G.
        • et al.
        Early revascularization in acute myocardial infarction complicated by cardiogenic shock.
        N Engl J Med. 1999; 341: 625-634
        • Roffi M.
        • Patrono C.
        • Collet J.-P.
        • et al.
        2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2016; 37: 267-315
        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • et al.
        2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes.
        Circulation. 2014; 130: e344-e426
        • Chang A.M.
        • Shofer F.S.
        • Tabas J.A.
        • Magid D.J.
        • McCusker C.M.
        • Hollander J.E.
        Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients.
        Am J Emerg Med. 2009; 27: 916-921
        • Neeland I.J.
        • Kontos M.C.
        • de Lemos J.A.
        Evolving considerations in the management of patients with left bundle branch block and suspected myocardial infarction.
        J Am Coll Cardiol. 2012; 60: 96-105
        • Wong C.-K.
        • French J.K.
        • Aylward P.E.G.
        • et al.
        Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes.
        J Am Coll Cardiol. 2005; 46: 29-38
      1. Collet J-P, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. The Task Force for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. Oxford Academic website. https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa575/5898842. Accessed September 15, 2020.

        • Jacobs A.K.
        • French J.K.
        • Col J.
        • et al.
        Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?.
        J Am Coll Cardiol. 2000; 36: 1091-1096
        • Kolte D.
        • Khera S.
        • Aronow W.S.
        • et al.
        Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.
        J Am Heart Assoc. 2014; 3: e000590
        • Thiele H.
        • Akin I.
        • Sandri M.
        • et al.
        PCI strategies in patients with acute myocardial infarction and cardiogenic shock.
        N Engl J Med. 2017; 377: 2419-2432
        • Thiele H.
        • Desch S.
        • Piek J.J.
        • et al.
        Multivessel versus culprit lesion only percutaneous revascularization plus potential staged revascularization in patients with acute myocardial infarction complicated by cardiogenic shock: design and rationale of CULPRIT-SHOCK trial.
        Am Heart J. 2016; 172: 160-169
        • Thiele H.
        • Akin I.
        • Sandri M.
        • et al.
        One-year outcomes after PCI strategies in cardiogenic shock.
        N Engl J Med. 2018; 379: 1699-1710
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • et al.
        Fourth universal definition of myocardial infarction (2018).
        Eur Heart J. 2019; 40: 237-269
        • Sgarbossa E.B.
        • Pinski S.L.
        • Barbagelata A.
        • et al.
        Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators.
        N Engl J Med. 1996; 334: 481-487
        • Savonitto S.
        • Ardissino D.
        • Granger C.B.
        • et al.
        Prognostic value of the admission electrocardiogram in acute coronary syndromes.
        JAMA. 1999; 281: 707-713
        • Zeymer U.
        • Vogt A.
        • Zahn R.
        • et al.
        Predictors of in-hospital mortality in 1333 patients with acute myocardial infarction complicated by cardiogenic shock treated with primary percutaneous coronary intervention (PCI); results of the primary PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK).
        Eur Heart J. 2004; 25: 322-328
        • Polonski L.
        • Gasior M.
        • Gierlotka M.
        • et al.
        A comparison of ST elevation versus non-ST elevation myocardial infarction outcomes in a large registry database: are non-ST myocardial infarctions associated with worse long-term prognoses?.
        Int J Cardiol. 2011; 152: 70-77
        • Zeitouni M.
        • Barthélémy O.
        • Hauguel-Moreau M.
        • et al.
        Investigator versus core laboratory evaluation of coronary flow and related mortality in the CULPRIT-SHOCK Trial.
        Circ Cardiovasc Interv. 2019; 12e008296
        • Bansilal S.
        • Aneja A.
        • Mathew V.
        • et al.
        Long-term cardiovascular outcomes in patients with angina pectoris presenting with bundle branch block.
        Am J Cardiol. 2011; 107: 1565-1570