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. 2020 Oct 1;180(10):1317-1327.
doi: 10.1001/jamainternmed.2020.3276.

Revascularization Practices and Outcomes in Patients With Multivessel Coronary Artery Disease Who Presented With Acute Myocardial Infarction and Cardiogenic Shock in the US, 2009-2018

Rohan Khera  1   2 , Eric A Secemsky  3   4 , Yongfei Wang  1   2 , Nihar R Desai  1   2 , Harlan M Krumholz  1   2 , Thomas M Maddox  5   6 , Kendrick A Shunk  7 , Salim S Virani  8 , Deepak L Bhatt  4   9 , Jeptha Curtis  1   2 , Robert W Yeh  3   4
Affiliations

Revascularization Practices and Outcomes in Patients With Multivessel Coronary Artery Disease Who Presented With Acute Myocardial Infarction and Cardiogenic Shock in the US, 2009-2018

Rohan Khera et al. JAMA Intern Med. .

Abstract

Importance: Cardiogenic shock after acute myocardial infarction (AMI) is associated with high mortality, particularly among patients with multivessel coronary artery disease. Recent evidence suggests that use of multivessel percutaneous coronary intervention (PCI) may be associated with harm. However, little is known about recent patterns of care and outcomes for this patient population.

Objective: To evaluate patterns in the use of multivessel PCI vs culprit-vessel PCI in AMI and cardiogenic shock and outcomes in the US from 2009 to 2018.

Design, setting, and participants: This cohort study identified all patients in the CathPCI Registry) with AMI and cardiogenic shock who had multivessel coronary artery disease and underwent PCI between July 1, 2009, and March 31, 2018.

Exposures: Multivessel or culprit-vessel PCI for AMI and shock.

Primary outcomes and measures: The primary outcome was in-hospital mortality. Temporal trends and hospital variation in PCI strategies were evaluated, while accounting for differences in case mix using hierarchical models. As a secondary outcome, the association of PCI strategy with postdischarge outcomes was evaluated in the subset of patients who were Medicare beneficiaries.

Results: Of 64 301 patients (mean [SD] age, 66.4 [12.5] years; 20 366 [31.7%] female; 54 538 [84.8%] White) with AMI and shock at 1649 US hospitals, 34.9% had primary multivessel PCI. In the subgroup of 48 943 patients with ST-segment elevation myocardial infarction (STEMI), 31.5% underwent multivessel PCI. Between 2009 and 2018, this percentage increased by 6.7% per year for AMI and 5.8% for STEMI. Overall, multivessel PCI was associated with a greater adjusted risk of in-hospital complications (odds ratio [OR], 1.18; 95% CI, 1.14-1.23) and with greater in-hospital mortality in patients with STEMI (OR, 1.11; 95% CI, 1.06-1.16). Among Medicare beneficiaries, multivessel PCI use was not associated with postdischarge 1-year mortality (51.5% vs 49.8%; risk-adjusted OR, 0.97; 95% CI, 0.90-1.04; P = .37). Significant hospital variation was found in the use of multivessel PCI, with a higher multivessel PCI rate for similar patients across hospitals (median OR, 1.37; 95% CI, 1.33-1.41). Patients at hospitals with high rates of PCI in STEMI use had higher risk-adjusted in-hospital mortality (highest vs lowest hospital multivessel PCI quartile: OR, 1.10; 95% CI, 1.02-1.19).

Conclusions and relevance: This cohort study found that multivessel PCI was increasingly used as the revascularization strategy in AMI and shock and that hospitals that used multivessel PCI more, especially among patients with STEMI, had worse outcomes. With recent evidence suggesting harm with this strategy, there appears to be an urgent need to change practice and improve outcomes in this high-risk population.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Khera was supported by grant UL1TR001105 from the National Center for Advancing Translational Sciences of the National Institutes of Health. Dr Secemsky reported receiving grants and personal fees from Cook, BD, Boston Scientific, Philips, Janssen, CSI, and Medtronic and grants from AstraZeneca and the University of California, San Francisco, outside the submitted work. Dr Desai reported receiving grants and personal fees from Amgen, Boehringer Ingelheim, Cytokinetics, Medicines Company, and Novartis and personal fees from Relypsa and SC Pharmaceuticals outside the submitted work. Dr Krumholz reported receiving personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, the Siegfried & Jensen Law Firm, the Arnold & Porter Law Firm, the Ben C. Martin Law Firm, the National Center for Cardiovascular Diseases in Beijing, China; ownership of HugoHealth and Refactor Health; receiving contracts with the Centers for Medicare & Medicaid Services; and receiving grants from Medtronic, the US Food and Drug Administration, Johnson & Johnson, and the Shenzhen Center for Health Information outside the submitted work. Dr Maddox reported receiving grants from the National Institutes of Health National Center for Advancing Translational Sciences; support for consulting for Creative Educational Concepts Inc and Atheneum Partners; and honoraria and/or expense reimbursement in the past 3 years from the University of Utah, NewYork Presbyterian, Westchester Medical Center, Sentara Heart Hospital, the Henry Ford Health System, and the University of California, San Diego; serves as an advisor for Myia Labs; and is a director for the J.F Maddox Foundation. Dr Shunk reported receiving grants from Siemens Medical Systems and Medinol, personal fees from Terumo and Syntactyx and performing contracted work for from PercAssist and TransAorticMedical outside the submitted work. Dr Virani reported receiving grants from the US Department of Veterans Affairs, the American Heart Association, the American Diabetes Association, and the World Heart Federation and honoraria from the American College of Cardiology and Patient and Provider Assessment of Lipid Management registry outside the submitted work. Dr Bhatt reported receiving grants from Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi-Aventis, The Medicines Company, Roche, Pfizer, Forest Laboratories, Ischemix, Amgen, Eli Lilly and Company, Chiesi, Ironwood, Abbott, Regeneron, Idorsia, Synaptic, Fractyl, Afimmune, and Lexicon; receiving nonfinancial support from FlowCo, Takeda, Medscape Cardiology, Regado Biosciences, and Boston Veterans Affairs Research Institute, Clinical Cardiology, Veterans Affairs, St. Jude Medical (now Abbott), Biotronik, Boston Scientific, Merck, Svelte, Novo Nordisk, Cereno Scientific, CSI, and Boehringer Ingelheim; receiving grants and nonfinancial support from PLx Pharma, Cardax, and PhaseBio; receiving personal fees from Duke Clinical Research Institute, Mayo Clinic, Population Health Research Institute, Belvoir Publications, Slack Publications, WebMD, Elsevier, HMP Global, Harvard Clinical Research Institute (now Baim Institute for Clinical Research), the Journal of the American College of Cardiology, Cleveland Clinic, Mount Sinai School of Medicine, TobeSoft, Bayer, Medtelligence/ReachMD, CSL Behring, Ferring Pharmaceuticals, MJH Life Sciences, Level Ex, and Boehringer Ingelheim; receiving personal fees, nonfinancial support, and nonfinancial support from the American College of Cardiology; receiving personal fees and nonfinancial support from Society of Cardiovascular Patient Care; and receiving nonfinancial support from the American Heart Association outside the submitted work. Dr Curtis reported receiving salary support under contract from the American College of Cardiology and the Centers for Medicare & Medicaid Services during the conduct of the study and has equity in Medtronic outside the submitted work. Dr Yeh reported receiving grants and personal fees from Abbott Vascular, Boston Scientific, and Medtronic outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Temporal Trends in Multivessel Percutaneous Coronary Intervention (PCI)
Trends are presented as monthly rates of multivessel PCI across the study period (July 2009-March 2018) (A) and across the 12-month period spanning the publication of the Culprit Lesion Only PCI vs Multi-vessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial in October 2017 (dotted vertical line) (B). AMI indicates acute myocardial infarction; CS, cardiogenic shock; MV-CAD, multivessel coronary artery disease; and STEMI, ST-segment elevation myocardial infarction.
Figure 2.
Figure 2.. Variation in the Use of Multivessel Percutaneous Coronary Intervention (PCI) Across Hospitals
The panels represent the frequency distribution plots for hospitals based on their multivessel PCI use to treat all AMI (A) and AMI with STEMI (B), shown as the percentage of procedures among all eligible patients. AMI indicates acute myocardial infarction; STEMI, ST-segment elevation myocardial infarction.
Figure 3.
Figure 3.. Risk-Adjusted Odds of In-Hospital Mortality and Any Procedural Complication Across Hospital Quartiles of Multivessel Percutaneous Coronary Intervention (PCI) Use
The panels represent) mortality in all patients with shock who had acute myocardial infarction (AMI) (A), mortality in patients with shock who had ST-segment elevation myocardial infarction (STEMI), any complication in all patients with shock who had AMI (C), and any complication in patients with shock who had STEMI (D). The reference group is hospitals in the lowest quartile (quartile 1) for multivessel PCI use in myocardial infarction and shock.
Figure 4.
Figure 4.. Postdischarge Long-term Outcomes in Acute Myocardial Infarction (AMI) Complicated With Cardiogenic Shock
Data are based on multivessel percutaneous coronary intervention (PCI) during index catheterization. AMI indicates acute myocardial infarction; MACE, major adverse cardiovascular event (including postdischarge death, recurrent AMI, or additional revascularization).
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