P3124Predictive value of the residual SYNTAX score following primary PCI in multivessel patients with MI-related cardiogenic shock - a CULPRIT SHOCK sub-analysis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
O Barthelemy ◽  
S Rouanet ◽  
D Brugier ◽  
N Vignoles ◽  
B Bertin ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Primary Endpoint ◽  
Circulatory Support ◽  
Syntax Score ◽  
Complete Revascularization ◽  
Prognostic Impact ◽  
Primary Pci ◽  
Culprit Lesion ◽  
Coronary Syndrome ◽  
Residual Syntax Score

Abstract Background Complete revascularization (CR) – assessed by the residual SYNTAX score (rSS) – following PCI is associated with a better prognosis – in stable coronary disease, acute coronary syndrome and myocardial infarction (MI). Whether, the completeness of revascularization impacts the prognosis of patients in cardiogenic shock (CS) remains unclear. Aim Assess the prognosis value of rSS following primary PCI in multivessel patients undergoing MI-related CS. Methods The CULPRIT SHOCK trial – the largest randomized trial (n=706) to date in CS – compared an immediate multivessel PCI (MVPCI) strategy to a culprit lesion only PCI (with possible staged revascularization) strategy in multivessel patients with MI-related CS. The rSS were retrospectively assessed following last PCI (either index or staged) by a central core laboratory and patients were allocated in 4 different groups according to rSS: CR (rSS=0), 0< rSS ≤5, 5< rSS ≤14, rSS >14. The prognostic impact of rSS on the 30-day composite endpoint (mortality and/or severe renal failure) and 30-day and 1-year mortality were assessed using multivariate logistic regression. Results Among the 604 patients with last rSS available, aged 68.2±11.4, the median rSS was 9.0 [4.0–17.0]. CR was achieved in 75 (25%) patients in the MVPCI strategy and in 31 (10.2%) in the culprit lesion only PCI strategy. One hundred and six (17.5%), 102 (16.9%), 198 (32.8%) and 198 (32.8%) patients had a rSS=0, 0< rss ≤5, 5< rSS ≤14 and rSS >14, respectively. Patients with a higher rSS were older, less active smoker, had more triple vessel disease, chronic total occlusion, post-PCI culprit coronary TIMI flow <3 and require more mechanical circulatory support and catecholamine. Univariate analysis shows a stepwise increase in adverse events according to rSS: patients with 5< rss ≤14 and rSS >14 had higher rates of 30-day primary endpoint (OR [95% CI]: 2.02 [1.24; 329] and 2.75 [1.69; 4.49]), 30-day mortality (OR [95% CI]: 2.13 [1.29; 3.51] and 3.14 [1.90; 5.18]) and 1-year mortality (OR [95% CI]: 2.39 [1.46; 3.90] and 3.47 [2.11; 5.71]) compared to patients with CR. After multiple adjustment, rSS – tested as continuous variable – was independently associated with 30-day primary endpoint, 30-day and one-year mortality (Figure) Conclusion Among multivessel patients with MI-related cardiogenic shock, 1) complete revascularization is achieved only in one fourth of the patients using a MVPCI strategy and, 2) the residual SYNTAX score is independently associated with early and late mortality. Acknowledgement/Funding Funded by the European Union 7th Framework Program and others

scholarly journals Prognostic Impact of Active Mechanical Circulatory Support in Cardiogenic Shock Complicating Acute Myocardial Infarction, Results from the Culprit-Shock Trial

2020 ◽  
Vol 9 (6) ◽  
pp. 1976
Author(s):  
Hans-Josef Feistritzer ◽  
Steffen Desch ◽  
Anne Freund ◽  
Janine Poess ◽  
Uwe Zeymer ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiogenic Shock ◽  
Primary Endpoint ◽  
Mechanical Circulatory Support ◽  
Circulatory Support ◽  
Prognostic Impact ◽  
Shock Trial ◽  
Artery Disease ◽  
Multivariable Adjustment

Objectives: To analyze the use and prognostic impact of active mechanical circulatory support (MCS) devices in a large prospective contemporary cohort of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). Background: Although increasingly used in clinical practice, data on the efficacy and safety of active MCS devices in patients with CS complicating AMI are limited. Methods: This is a predefined subanalysis of the CULPRIT-SHOCK randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups: (1) use of at least one active MCS device vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or renal replacement therapy at 30 days. Results: Two hundred of 1055 (19%) patients received at least one active MCS device (n = 112 Impella®; n = 95 extracorporeal membrane oxygenation (ECMO); n = 6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared with those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p < 0.001). All-cause mortality and bleeding rates were significantly higher in the active MCS group (all p < 0.001). After multivariable adjustment, the use of active MCS was significantly associated with the primary endpoint (odds ratio (OR) 4.0, 95% confidence interval (CI) 2.7–5.9; p < 0.001). Conclusions: In the CULPRIT-SHOCK trial, active MCS devices were used in approximately one fifth of patients. Patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

scholarly journals THE RESIDUAL SYNTAX SCORE FOR MORTALITY RISK ASSESSMENT IN ACUTE CORONARY SYNDROME WITH CARDIOGENIC SHOCK

2013 ◽  
Vol 61 (10) ◽  
pp. E20 ◽  
Author(s):  
Hidenori Adachi ◽  
Yoshinori Yasuoka ◽  
Kiyoshi Kume ◽  
Susumu Hattori ◽  
Yoshiki Noda ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Acute Coronary Syndrome ◽  
Cardiogenic Shock ◽  
Mortality Risk ◽  
Syntax Score ◽  
Coronary Syndrome ◽  
Residual Syntax Score

scholarly journals Complete Revascularisation in Impella-Supported Infarct-Related Cardiogenic Shock Patients Is Associated With Improved Mortality

2021 ◽  
Vol 8 ◽  
Author(s):  
Andreas Schäfer ◽  
Ralf Westenfeld ◽  
Jan-Thorben Sieweke ◽  
Andreas Zietzer ◽  
Julian Wiora ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Mechanical Circulatory Support ◽  
High Volume ◽  
Lower Mortality ◽  
Circulatory Support ◽  
Syntax Score ◽  
Urgent Revascularisation ◽  
Complete Revascularisation ◽  
Residual Syntax Score ◽  
Trial Evidence

Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients.Objectives: We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients.Methods: We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage (n = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was &gt;8.Results: Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, p = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS &gt; 8: 56%, p = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, p &lt; 0.001).Conclusions: Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.

Prognostic impact of active mechanical circulatory support in cardiogenic shock complicating acute myocardial infarction: results from the CULPRIT-SHOCK trial

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
H Feistritzer ◽  
S Desch ◽  
A Freund ◽  
J Poess ◽  
U Zeymer ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Cardiogenic Shock ◽  
Randomized Trial ◽  
Primary Endpoint ◽  
Mechanical Circulatory Support ◽  
Circulatory Support ◽  
Funding Source ◽  
Prognostic Impact ◽  
Heart Research

Abstract Background Active mechanical circulatory support (MCS) devices are increasingly used in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). However, data derived from randomized controlled trials on the efficacy and safety of these devices are still limited. Purpose To analyze the prognostic impact of active MCS devices in a large prospective contemporary cohort of patients with CS complicating AMI. Methods This is a predefined subanalysis of the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups; (1) use of at least one active MCS device, vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or need of renal replacement therapy at 30 days. Results Two hundred of 1055 (19%) patients received at least one active MCS device (n=112 Impella®; n=95 extracorporeal membrane oxygenation [ECMO]; n=6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared to those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p&lt;0.001). All-cause mortality at 30 days and 1 year as well as bleeding rates were significantly higher in the active MCS group (all p&lt;0.001). After multivariable adjustment the use of active MCS was significantly associated with the primary endpoint (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.7–5.9; p&lt;0.001). Conclusion In the CULPRIT-SHOCK randomized trial and prospective registry approximately one fifth of patients was treated with active MCS devices. Compared to patients without active MCS, patients treated with active MCS devices showed worse outcome at 30 days and 1 year. Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): Supported by a grant (FP7/2007-2013) from the European Union 7th Framework Program and by the German Heart Research Foundation and the German Cardiac Society.

Influence of age and shock severity on short-term survival in patients with cardiogenic shock

2021 ◽  
Author(s):  
Jacob C Jentzer ◽  
Benedikt Schrage ◽  
David R Holmes ◽  
Salim Dabboura ◽  
Nandan S Anavekar ◽  
...  
Keyword(s):  
Cardiogenic Shock ◽  
Mayo Clinic ◽  
Older Patients ◽  
Cox Proportional Hazards ◽  
Circulatory Support ◽  
Short Term ◽  
Term Survival ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
Short Term Survival

Abstract Aims Cardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS. Methods and results Patients with a diagnosis of CS from Mayo Clinic (2007–15) and University Clinic Hamburg (2009–17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged &lt;50 years. Conclusion Older patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients.

scholarly journals Residual SYNTAX Score After Revascularization in Cardiogenic Shock

2021 ◽  
Vol 77 (2) ◽  
pp. 156-158
Author(s):  
Ajar Kochar ◽  
Anubodh S. Varshney ◽  
David E. Wang
Keyword(s):  
Cardiogenic Shock ◽  
Syntax Score ◽  
Residual Syntax Score

Cardiogenic shock in patients with acute coronary syndromes

2015 ◽  
Author(s):  
Holger Thiele ◽  
Uwe Zeymer
Keyword(s):  
Intensive Care ◽  
Cardiogenic Shock ◽  
Acute Coronary Syndromes ◽  
Artery Bypass ◽  
Left Ventricular ◽  
Circulatory Support ◽  
Intensive Care Treatment ◽  
Post Discharge ◽  
Coronary Syndrome ◽  
Coronary Syndromes

Cardiogenic shock complicating an acute coronary syndrome is observed in up to 10% of patients and is associated with high mortality still approaching 50%. The extent of ischaemic myocardium has a profound impact on the initial, in-hospital, and post-discharge management and prognosis of the cardiogenic shock patient. Careful risk assessment for each patient, based on clinical criteria, is mandatory, to decide appropriately regarding revascularization by primary percutaneous coronary intervention or coronary artery bypass grafting, drug treatment by inotropes and vasopressors, mechanical left ventricular support, additional intensive care treatment, triage among alternative hospital care levels, and allocation of clinical resources. This chapter will outline the underlying causes and diagnostic criteria, pathophysiology, and treatment of cardiogenic shock complicating acute coronary syndromes, including mechanical complications and shock from right heart failure. There will be a major focus on potential therapeutic issues from an interventional cardiologist’s and an intensive care physician’s perspective on the advancement of new therapeutical arsenals, both mechanical percutaneous circulatory support and pharmacological support. Since studying the cardiogenic shock population in randomized trials remains challenging, this chapter will also touch upon the specific challenges encountered in previous clinical trials and the implications for future perspectives in cardiogenic shock.

scholarly journals Prognostic Impact of Residual Anatomic Disease Burden After Functionally Complete Revascularization

2020 ◽  
Vol 13 (9) ◽  
Author(s):  
Joo Myung Lee ◽  
Doyeon Hwang ◽  
Ki Hong Choi ◽  
Hyun-Jong Lee ◽  
Young Bin Song ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Disease Burden ◽  
Coronary Intervention ◽  
Hazard Ratio ◽  
Syntax Score ◽  
Complete Revascularization ◽  
Prognostic Impact ◽  
Target Vessel ◽  
Fractional Flow ◽  
Percutaneous Coronary

Background: Prognostic impact of residual anatomic disease burden after functionally complete percutaneous coronary intervention (PCI), defined by post-PCI fractional flow reserve (FFR) >0.80 would be a clinically relevant question. The current study evaluated clinical outcomes at 2 years according to residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (RSS) in patients who underwent functionally complete revascularization. Methods: A total of 1910 patients (2095 revascularized vessels) with post-PCI FFR >0.80 were selected from the International Post-PCI FFR Registry. RSS was defined as the SYNTAX score recalculated after PCI, SYNTAX revascularization index was calculated as 100×(1−RSS/pre-PCI SYNTAX score), and post-PCI FFR was measured after completion of PCI. The primary outcome was target vessel failure (TVF; a composite of cardiac death, target vessel–related myocardial infarction, and clinically driven target vessel revascularization) at 2 years, and risk of TVF was compared according to tertile classification of RSS (0, 1–5, and >5) and post-PCI FFR (≥0.94, 0.87–0.93, and ≤0.86). Results: After PCI, SYNTAX score was changed from 10.0 (Q1–Q3, 7.0–16.0) to 0.0 (Q1–Q3, 0.0–5.0) and FFR changed from 0.70±0.12 to 0.90±0.05. TVF at 2 years occurred in 4.9%, and patients with TVF showed higher pre-PCI SYNTAX score and lower post-PCI FFR than those without. However, there were no significant differences in SYNTAX revascularization index and RSS. The risk of TVF was not different according to tertile of RSS (log-rank P =0.851). Conversely, risk of TVF was different according to tertile of post-PCI FFR (log-rank P =0.009). Multivariable model showed the risk of TVF was significantly associated with post-PCI FFR (hazard ratio, 1.091 [95% CI, 1.032–1.153]; P =0.002) but not with RSS (hazard ratio, 0.969 [95% CI, 0.898–1.045]; P =0.417). Conclusions: Among patients who underwent functionally complete revascularization, residual anatomic disease burden assessed by RSS was not related with occurrence of TVF at 2 years. These results support the importance of functionally complete revascularization rather than angiographic complete revascularization. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT04012281.

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