Clinical outcomes according to ECG presentations in infarct-related cardiogenic shock in CULPRIT-SHOCK

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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 (NSTE-MI) and left bundle branch block (LBBB-MI) versus STEMI?

Methods

Cardiogenic shock patients from the CULPRIT-SHOCK trial presenting with NSTE-MI or LBBB-MI were compared with STE-MI 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% presented with STE-MI, 29.3% with NSTE-MI and 14.7% with LBBB-MI. Patients differed in age (68.0 years in STE-MI, 71.0 years in NSTE-MI and 73.5 years in LBBB-MI, p=0.015), cardiovascular risk factors and angiographic severity. There was no difference in the 30-day risk of death between NSTE-MI and STE-MI (48.7 % vs. 43.0%, aOR 1.05, 95%CI, 0.66 - 1.67, p=0.85), nor between LBBB-MI and STE-MI (59.2% vs. 43.0%, aOR 1.31, 95%CI 0.73 - 2.34, p=0.36). While the univariate risk of 1-year death was higher in NSTE-MI and LBBB-MI patients compared with STE-MI, ECG presentation was not an independent risk factor of mortality after adjustment (NSTE-MI vs. STE-MI : 56.4 % vs 46.8 % aOR 1.21, 95%CI 0.76 - 1.92, p=0.42 ; LBBB-MI vs. STEMI : 69.4% vs. 46.8% : aOR : 1.59, 95%CI 0.89 – 2.84, p=0.12) . ECG presentation did not modify the effect of the revascularization strategy on 30-day and 1-year mortality (p interaction =0.91 and 0.97).

Interpretation

In patients with cardiogenic shock, NSTE-MI and LBBB-MI presentations reflect higher risk profiles than STE-MI but are not independent risk factors of mortality. ECG presentations did not modify the treatment effect, supporting culprit-lesion-only PCI as the preferred strategy across the AMI spectrum.



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