Barts Health NHS Trust, London, United Kingdom of Great Britain and Northern Ireland.
Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom of Great Britain and Northern Ireland.
Cardiovasc Revasc Med. 2020 Mar;21(3):350-358. doi: 10.1016/j.carrev.2019.06.007. Epub 2019 Jun 18.
Despite advances in technology, patients with Cardiogenic Shock (CS) presenting with ST-segment myocardial infarction (STEMI) still have a poor prognosis with high mortality rates. A large proportion of these patients have multi-vessel coronary artery disease, the treatment of which is still unclear. We aimed to assess the trends in management of CS patients with multi-vessel disease (MVD), particularly looking at the incidence and outcomes of complete revascularisation compared to culprit vessel only.
We undertook an observational cohort study of 21,210 STEMI patients treated between 2005 and 2015 at the 8 Heart Attack Centres in London, UK. Patients' details were recorded prospectively into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. 1058 patients presented with CS and MVD. Primary outcome was all-cause mortality. Patients were followed-up for a median of 4.1 years (IQR range: 2.2-5.8 years). 497 (47.0%) patients underwent complete revascularisation during primary PCI for CS with stable rates seen over time. These patients were more likely to be male, hypertensive and more likely to have poor LV function compared to the culprit vessel intervention group. Although crude, in hospital major adverse cardiac events (MACE) rates were similar (40.8% vs. 36.0%, p = 0.558) between the two groups. Kaplan-Meier analysis demonstrated no significant differences in mortality rates between the two groups (53.8% complete revascularisation vs. 46.8% culprit vessel intervention, p = 0.252) during the follow-up period. After multivariate cox analysis (HR 0.69 95% CI (0.44-0.98)) and the use of propensity matching (HR: 0.81 95% CI: 0.62-0.97) complete revascularisation was associated with reduced mortality. A number of co-variates were included in the model, including age, gender, diabetes, hypertension, hypercholesterolaemia, previous PCI, previous MI, chronic renal failure, Anterior infarct, number of treated vessels, pre-procedure TIMI flow, procedural success and GP IIb/IIIA use.
In a contemporary observational series of CS patients with MVD, complete revascularisation appears to be associated with better outcomes compared to culprit vessel only intervention. This supports on-going clinical trials in this area and provides further evidence of the association of complete revascularisation in STEMI with good outcomes.
尽管技术不断进步，但患有心源性休克（CS）并伴有 ST 段抬高型心肌梗死（STEMI）的患者死亡率仍然很高，预后不佳。这些患者中有很大一部分患有多支血管冠状动脉疾病，但其治疗方法仍不明确。我们旨在评估多支血管疾病（MVD）CS 患者治疗管理的趋势，特别是比较完全血运重建与罪犯血管血运重建的发生率和结果。
我们对英国伦敦 8 个心脏病中心于 2005 年至 2015 年期间治疗的 21210 例 STEMI 患者进行了一项观察性队列研究。使用英国心脏介入学会（BCIS）PCI 数据集前瞻性地记录患者的详细信息。21210 例 STEMI 患者中有 1058 例出现 CS 和 MVD。主要结局是全因死亡率。中位随访时间为 4.1 年（IQR 范围：2.2-5.8 年）。497 例（47.0%）CS 患者在首次 PCI 时进行了完全血运重建，且该比例随时间保持稳定。与罪犯血管介入组相比，这些患者更可能为男性、高血压且左心室功能更差。尽管未经校正，两组之间的住院期间主要不良心脏事件（MACE）发生率相似（40.8% vs. 36.0%，p=0.558）。Kaplan-Meier 分析显示，两组之间在随访期间死亡率无显著差异（完全血运重建组为 53.8%，罪犯血管介入组为 46.8%，p=0.252）。多变量 Cox 分析（HR 0.69，95%CI（0.44-0.98））和倾向匹配（HR：0.81，95%CI：0.62-0.97）后发现，完全血运重建与死亡率降低相关。模型中包含了许多协变量，包括年龄、性别、糖尿病、高血压、高胆固醇血症、既往 PCI、既往 MI、慢性肾衰竭、前壁梗死、治疗血管数量、术前 TIMI 血流、手术成功率和 GP IIb/IIIa 应用。
在一项多支血管疾病 CS 患者的当代观察性系列研究中，与仅罪犯血管介入相比，完全血运重建似乎与更好的结局相关。这支持该领域正在进行的临床试验，并进一步证明 STEMI 中的完全血运重建与良好结局相关。
