Complexity of coronary artery disease in infarct-related cardiogenic shock and multivessel disease: a substudy of the DanGer Shock trial

BACKGROUND: The prognostic impact of multivessel coronary anatomy and complexity in infarct-related cardiogenic shock (CS) is insufficiently characterised. AIMS: We sought to investigate the prognostic value of baseline and residual SYNTAX scores and their influence on the effect of microaxial flow pump (mAFP) support in multivessel disease (MVD) and infarct-related CS. METHODS: In this secondary analysis of the DanGer Shock trial, MVD was defined as >=1 non-culprit stenosis >=70% or an isolated left main (LM) culprit lesion. Baseline SYNTAX scores were categorised as low (<=22), intermediate (23-32), or high (>32). Patients with an isolated LM culprit lesion were analysed separately. The primary outcome was 180-day all-cause mortality. RESULTS: Of 355 patients included in DanGer Shock, 256 patients had MVD; 211 had an available baseline SYNTAX score, with 26% of these in the low, 47% in the intermediate, and 27% in the high baseline SYNTAX groups. In all, 35 patients had an isolated LM culprit lesion. A high baseline SYNTAX score was associated with higher odds of 180-day all-cause mortality compared with low and intermediate baseline SYNTAX scores (adjusted odds ratio [OR] 3.12, 95% confidence interval [CI]: 1.17-8.69). A higher baseline SYNTAX score was associated with a higher residual SYNTAX score (p<0.001). The residual SYNTAX score independently predicted 180-day all-cause mortality. The mAFP effect was not modified by the baseline SYNTAX group (p for interaction=0.31). In patients with an isolated LM culprit lesion, mAFP use was associated with lower odds of 180-day all-cause mortality compared with standard care alone (adjusted OR 0.17, 95% CI: 0.03-0.99). CONCLUSIONS: Baseline and residual SYNTAX scores independently predicted 180-day mortality. The mAFP effect was not modified by SYNTAX measures. In the isolated left main subgroup, a hypothesis-generating signal towards a clinical benefit with mAFP use was observed.