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Non-culprit Left Main Coronary Artery Disease in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Ik Hyun Park, Woo Jin Jang, Ju Hyeon Oh, Jeong Hoon Yang, Young Bin Song, Joo-Yong Hahn, Seung-Hyuk Choi, Hyeon-Cheol Gwon,Chul-Min Ahn, Cheol Woong Yu, Hyun-Joong Kim, Jang-Whan Bae, Sung Uk Kwon, Hyun-Jong Lee, Wang Soo Lee, Jin-Ok Jeong, Sang-Don Park

Abstract

Objectives

We evaluated the clinical impact of residual non-culprit left main coronary artery disease (LMCAD) on prognosis in patients undergoing emergent percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock (CS).

Introduction

Left main coronary artery disease (LMCAD) is incidentally identified in 5~7% of patients undergoing coronary angiography [1]. Culprit LMCAD in patients with acute myocardial infarction (AMI) is considered a high-acuity and critical status because cardiogenic shock (CS) or cardiac arrest is a frequent complication associated with higher mortality. The question then arises as to whether non-culprit LMCAD is also related to adverse clinical outcomes in AMI complicated by CS. The COMPLETE trial showed that complete revascularization (CR) including non-culprit coronary stenoses, either at the time of the index procedure or as a staged procedure, is superior to a culprit-only strategy in reducing cardiovascular risk among AMI patients with multi-vessel disease [2]. However, the ISCHEMIA study reported that conservative medical treatment had similar mortality compared to an initial invasive strategy for stable coronary disease including multi-vessel disease and LMCAD [3]. These two previous studies included few AMI patients complicated by CS or those with LMCAD. We still have no data about the prognostic effect and optimal treatment strategy of non-culprit LMCAD in AMI patients with CS. This study evaluated the clinical impact of residual non-culprit LMCAD on long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) for AMI complicated by CS.

Materials and Methods

Study population

The design of the RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock, NCT02985008) registry has been described previously [4]. In brief, between January 2014 and December 2018, a total of 1,247 CS patients older than 19 years was recruited from 12 Korean tertiary care centers. The criteria for CS included systolic blood pressure <90 mmHg for 30 minutes or need for inotrope or vasopressor support to achieve a systolic blood pressure >90 mmHg, and the presence of pulmonary congestion and signs of impaired organ perfusion (altered mental status, cold skin, urine output <0.5 mL/kg/h for the previous six hours, or blood lactate >2.0 mmol/L). Patients with out-of-hospital cardiac arrest, other causes of shock, and those who refused active treatment were excluded from this registry.

Results

Baseline clinical characteristics

Among the 429 patients enrolled in this study, 43 were identified with residual non-culprit LMCAD after index PCI (10.1%, LMCAD non-culprit group) and the remaining 386 (89.9%) comprised the no LMCAD group. The mean age and body mass index of the study population were 68.1 ± 12.1 years and 23.6 ± 3.3, respectively. The incidence of diabetes mellitus was higher in the LMCAD non-culprit group than in the no LMCAD group (p = 0.029), but the rate of current smokers was lower in the LMCAD non-culprit group compared to the no LMCAD group (p = 0.026).

Discussion

This study investigated the clinical impact of non-culprit LMCAD on 12-month clinical outcomes in patients treated with PCI for AMI complicated by CS using a dedicated, large-scale, multicenter real-world CS registry. The main study finding was that there was no significant difference in risk of a composite of cardiac death, myocardial infarction, or repeat revascularization during 12 months between the LMCAD non-culprit group and the no LMCAD group. This was consistent across subgroups by use of ECMO support and a variety of other clinical factors. To the best of our knowledge, this is the first study specifically concerned with the prognostic effect of residual non-culprit LMCAD in patients undergoing emergent PCI for AMI complicated by CS.

Conclusion

In patients treated with PCI for AMI complicated by CS, there was no significant difference in the 12-month risk of MACE and secondary outcomes between the LMCAD non-culprit and the no LMCAD groups. The similarity of 12-month MACE between the two groups was consistent across various subgroups. Based on our results, residual non-culprit LMCAD does not seem to influence clinical outcomes for 12 months after the index PCI in patients with AMI complicated by CS. Further investigations in a shock setting are required to confirm this finding.

Citation: Park IH, Jang WJ, Oh JH, Yang JH, Song YB, Hahn J-Y, et al. (2023) Non-culprit left main coronary artery disease in acute myocardial infarction complicated by cardiogenic shock. PLoS ONE 18(3): e0276711. https://doi.org/10.1371/journal.pone.0276711

Editor: Annunziata Nusca, Campus Biomedico University of Rome, ITALY

Received: October 11, 2022; Accepted: February 27, 2023; Published: March 30, 2023

Copyright: © 2023 Park et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

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