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Rhee, Tae-Min; Lee, Joo Myung; Choi, Ki Hong; Kim, Jihoon; Kim, Hyun Kuk; Song, Young Bin; Hahn, Joo-Yong The KAMIR Investigators

doi: 10.1097/EDE.0000000000000885
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Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea

Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea

Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, jyhahn@skku.edu, ichjy1@gmail.com

T.-M.R. and J.M.L. contributed equally to this work.

The authors report no conflicts of interest.

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To the Editor:

We would like to thank Secemsky and Yeh1 for their interest in our recent work regarding prognostic impact of multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction and cardiogenic shock.2 Drs. Secemsky and Yeh1 pointed out “immortal time bias” as explanation for improved outcomes after multivessel percutaneous coronary intervention (PCI) compared with infarct-related artery-only PCI. As described in our article published in the Journal of the American College of Cardiology,2 40% of patients in the multivessel PCI group underwent staged PCI during the same hospitalization. To clarify the issue raised by Drs. Secemsky and Yeh,1 we would like to present the results of 2 additional analyses in this letter.

First, we excluded patients undergoing staged multivessel PCI and compared outcomes between the “immediate” multivessel PCI group (n = 157) and the infarct-related-only PCI group (n = 359). The risk of patient-oriented composite outcome at 1 year was still lower in the immediate multivessel PCI group than in the infarct-related-only PCI group (34% vs. 43%, inverse probability weighting [IPW]-adjusted hazard ratio [HR] = 0.70; 95% confidence interval [CI] = 0.53, 0.94).

Second, landmark analysis after discharge from the index hospitalization consistently showed that the risk of patient-oriented composite outcome at 1 year was lower in the multivessel PCI group than infarct-related-only PCI group (13% vs. 22%, IPW-adjusted HR = 0.50; 95% CI = 0.33, 0.77). Furthermore, that the risk of death or myocardial infarction at 1 year was also lower in the multivessel PCI group than in the infarct-related-only PCI group at landmark analysis (7.3% vs. 13%, IPW-adjusted HR = 0.46; 95% CI = 0.26, 0.82).

It should be noted that all previous trials (except the Culprit Lesion Only PCI vs. Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK)) comparing complete revascularization with infarct-related-only PCI classified staged noninfarct-related-only PCI as multivessel PCI or complete revascularization group and consistently demonstrated superiority of complete revascularization than infarct-related-only PCI.3–6 Furthermore, the CULPRIT-SHOCK trial mandated immediate PCI for chronic total occlusion lesions in the noninfarct-related-only group. However, immediate attempt for chronic total occlusion PCI cannot be recommended for patients with cardiogenic shock because of unclear benefit, possibility of contrast overload and risk of deterioration of renal function, and increased risk of procedural complication.

We would like to sincerely appreciate Drs. Secemsky and Yeh for giving us the opportunity to further clarify our results. In daily practice, many experienced interventional cardiologists struggle to improve outcomes of patients with cardiogenic shock and seriously consider complete revascularization and mechanical circulatory support instead of giving them Cheetos. Further well-designed randomized trials are strongly warranted to shed the light on this issue in acute myocardial infarction patients presented with cardiogenic shock.

Tae-Min Rhee

Division of Cardiology

Department of Internal Medicine

Heart Vascular Stroke Institute

Samsung Medical Center

Sungkyunkwan University School of Medicine

eoul, Korea

Department of Internal Medicine and Cardiovascular Center

Seoul National University Hospital

Seoul, Korea

Joo Myung Lee

Ki Hong Choi

Jihoon Kim

Division of Cardiology

Department of Internal Medicine

Heart Vascular Stroke Institute

Samsung Medical Center

Sungkyunkwan University School of Medicine

Seoul, Korea

Hyun Kuk Kim

Department of Internal Medicine and Cardiovascular Center

Chosun University Hospital

University of Chosun College of Medicine

Gwangju, Korea

Young Bin Song

Joo-Yong Hahn

Division of Cardiology

Department of Internal Medicine

Heart Vascular Stroke Institute

Samsung Medical Center

Sungkyunkwan University School of Medicine

Seoul, Korea, jyhahn@skku.edu, ichjy1@gmail.com

The KAMIR Investigators

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REFERENCES

1. Secemsky EA, Yeh RW. Re. Multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction with cardiogenic shock. Epidemiology. 2018;29:e59e60.
2. Lee JM, Rhee TM, Hahn JY, et al; KAMIR Investigators. Multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction with cardiogenic shock. J Am Coll Cardiol. 2018;71:844–856.
3. Engstrøm T, Kelbæk H, Helqvist S, et al; DANAMI-3—PRIMULTI Investigators. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386:665–671.
4. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65:963–972.
5. Smits PC, Abdel-Wahab M, Neumann FJ, et al; Compare-Acute Investigators. Fractional flow reserve-guided multivessel angioplasty in myocardial infarction. N Engl J Med. 2017;376:1234–1244.
6. Wald DS, Morris JK, Wald NJ, et al; PRAMI Investigators. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369:1115–1123.
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