Key result
NSTEMI and LBBBMI show no difference in 30-day mortality compared to STEMI in cardiogenic shock.
Why the study?
The impact of different ECG presentations of acute myocardial infarction (NSTEMI and LBBBMI vs STEMI) on outcomes and the effect of revascularization strategies in patients with cardiogenic shock was unknown.
In myocardial infarction with cardiogenic shock, is there a difference in all-cause mortality and the effect of revascularization strategies between NSTEMI and LBBBMI vs STEMI presentations?
Cohort (n=665)
In myocardial infarction with cardiogenic shock, is there a difference in all-cause mortality and the effect of revascularization strategies between NSTEMI and LBBBMI vs STEMI presentations?
In infarct-related cardiogenic shock, NSTEMI and LBBBMI presentations are not independent predictors of mortality after adjustment and do not modify the benefit of culprit-lesion-only PCI over multivessel PCI.
Answers are grounded in this paper and cite their sources.
May support equivalent risk stratification across presentations in MI shock; hypothesis-generating for revascularization strategy effects.
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.
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Zeitouni et al. (2020) conducted a cohort in Infarct-related cardiogenic shock (n=665). NSTEMI or LBBBMI presentation vs. STEMI presentation was evaluated on 30-day all-cause mortality (NSTEMI vs STEMI) (OR 1.05, 95% CI 0.66-1.67, p=0.85). NSTEMI and LBBBMI presentations were not independent predictors of 30-day mortality vs STEMI in cardiogenic shock (NSTEMI aOR 1.05, 95% CI 0.66-1.67; LBBBMI aOR 1.31, 95% CI 0.73-2.34).
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