In patients with myocardial infarction (MI)-related cardiogenic shock (CS), complete revascularization (CR) is achieved in only 25% of patients with the residual SYNTAX score (rSS), an independent predictor of early and late mortality, according to CULPRIT-SHOCK substudy results released Monday.
The CULPRIT-SHOCK (Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock) trial demonstrated that culprit vessel percutaneous coronary intervention (PCI) was more effective and safer than immediate multivessel PCI. The extent of residual coronary disease, using the rSS, and its implications on outcomes in this cohort remained unclear.
Olivier Barthélémy, MD, of the University of the Sorbonne, Paris, and co-investigators, reported results from the CULPRIT-SHOCK substudy in a manuscript published in the Jan. 19 issue of the Journal of the American College of Cardiology.
The authors investigated the extent of coronary artery disease (CAD) following PCI and the prognostic value of the rSS in these patients with MI-related CS. Patients in the substudy were divided into four cohorts based on their rSS. The substudy’s primary outcomes included mortality or severe renal failure at 30 days. Additional outcomes included 1-year mortality.
Included were 587 patients, who had a median rSS of 9.0 (interquartile range: 3.0 to 17.0). Patients were divided into those with an rSS of 0 and tertiles based on rSS (0<rSS<5, 5<rSS<14, rSS>14). Using multivariate logistic regression, rSS was found to be independently associated with 30-day mortality (adjusted odds ratio [OR] per 10 units, 1.49; 95% confidence interval [CI]: 1.11, 2.01) as well as 1-year mortality (adjusted OR per 10 units, 1.52; 95% CI: 1.11, 2.07).
Ajar Kochar, MD, of Brigham and Women’s Hospital, Harvard Medical School, Boston, and colleagues wrote an accompanying editorial to the study. They began by acknowledging the dearth of literature regarding the prognostic value of rSS in patients with MI-related CS. They applauded the authors' use of an angiographic core lab to calculate the rSS in the trial. Despite the results of this study, which contrasts with those of the initial trial, readers should keep in mind that the results of this study are derived from a secondary analysis and should be considered hypothesis-generating at best, the editorialists wrote.
The higher rSS cohort probably represents a higher-risk cohort, as there were probably unmeasured confounders unaccounted for in this secondary analysis. Finally, coronary artery bypass grafting (CABG) occurred in just one patient in culprit-lesion only PCI group, leaving the question of CABG for complete revascularization in MI-related CS unanswered, Kochar and colleagues wrote.
Barthélémy O, Rouanet S, Brugier D, et al. Predictive Value of the Residual SYNTAX Score in Patients With Cardiogenic Shock. J Am Coll Cardiol 2021;77:144–55.
Kochar A, Varshney AS, Wang DE. Residual SYNTAX Score After Revascularization in Cardiogenic Shock: When Is Complete Complete? J Am Coll Cardiol 2021;77:156–8.