Prognostic Utility of Culprit SYNTAX Score in Patients With Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction

A higher SYNTAX score (SS) is strongly associated with poor prognosis in patients cardiogenic shock complicating ST-segment elevation myocardial infarction (CS-STEMI). However, the predictive value of culprit-lesion (cul-SS) and SS has not been compared although culprit-lesion-only primary percutaneous coronary intervention (PCI) strategy showed improved long-term survival recently. This study utility cul-SS for in-hospital mortality among CS-STEMI from during 2010–2019. Of 215 patients, 79 (37%) died. ≥22, ≥11, final thrombolysis (TIMI) flow ≤2, no-reflow phenomenon were mortality. In multi-vessel disease, nonsurvivors ≥11 had a rate than survivors (75.0% vs. 44.9%, p = 0.001), whereas ≥22 no significant difference. The revealed only an independent factor multivariate analysis (OR 2.6, 0.010). AUC was modest (0.617 < 0.05), which might be augmented up to 0.745 (p 0.001) by combination TIMI phenomenon, blood total CO2 content <15 mEq/L. more our CS-STEMI. Syntax (Synergy between Percutaneous Coronary Intervention TAXUS Cardiac Surgery score, SS) angiographic grading tool that quantifies artery disease based on number, location, complexity lesion.1Sianos G Morel M-A Kappetein AP Morice M-C Colombo Dawkins K Brand M van den Van Dyck N Russell ME Mohr FW Serruys PW Score: disease.EuroIntervention. 2005; 1: 219-227PubMed Google Scholar reported have prognostic various clinical presentations disease.2Serruys Onuma Y Garg S Sarno A-P Mack Holmes D Feldman T Bass E Leadley KD Es G-A M-AM Assessment syntax study.EuroIntervention. 2009; 5: 50-56Crossref PubMed Scopus (413) Scholar, 3Li Q Yu X He J Gao Zhang Wu C Luo Ren Lv Chen F. relationship revascularization extent stable angina pectoris three-vessel treated era drug-eluting stents.Clin Cardiol. 2014; 37: 566-575PubMed 4Palmerini Genereux P Caixeta Cristea Lansky Mehran R Dangas Lazar Sanchez Fahy Xu Stone GW Prognostic acute syndromes undergoing intervention: ACUITY (Acute Catheterization Urgent Triage StrategY) trial.J Am Coll 2011; 57: 2389-2397Crossref (202) 5Onuk Güngör B İpek Karataş MB Çanga Akyüz Ş Haci Karadeniz FÖ Sungur Kaşikçioğlu H Çam Comparison baseline scores multivessel disease.Coron Artery Dis. 2016; 27: 311-318Crossref (4) 6Yoon Y-H Ahn J-M Kang D-Y Park Cho S-C Lee PH S-W D-W S-J. Impact 10-Year outcomes after left main disease.JACC Cardiovasc Interv. 2020; 13: 361-371Crossref (6) there inadequate number data predicting hemodynamically unstable ST (STEMI).7Javanainen Sans-Roselló Harjola V-P Nieminen MS Lassus Sionis Varpula Jurkko R. impact residual shock.Catheter 2019; 93: 1-8Crossref Cardiogenic (CS) STEMI (CS-STEMI) last target improve patients. tends stagnant (approximately 40%–50%) even era.8Wayangankar SA Bangalore McCoy LA Jneid Latif F Karrowni W Charitakis DN Dakik HA Mauri L Peterson ED Messenger Roe Mukherjee Klein A. Temporal trends interventions setting infarction: report CathPCI registry.JACC 9: 341-351Crossref (144) There debate regarding early culprit-only index procedures CULPRIT-SHOCK trial9Thiele Akin I Sandri Fuernau Waha Sde Meyer-Saraei Nordbeck Geisler Landmesser U Skurk Fach Lapp Piek JJ Noc Goslar Felix SB Maier LS Stepinska Oldroyd Serpytis Montalescot Barthelemy O Huber Windecker Savonitto Torremante Vrints Schneider Desch Zeymer InvestigatorsPCI strategies shock.N Engl Med. 2017; 377: 2419-2432Crossref (431) demonstrated safer better outcome immediate revascularization, results contrast other studies hemodynamics.10Smits PC Abdel-Wahab Neumann Boxma-de Klerk BM Lunde Schotborgh CE Piroth Z Horak Wlodarczak Ong PJ Hambrecht Angerås Richardt Omerovic Compare-Acute InvestigatorsFractional reserve-guided angioplasty infarction.N 376: 1234-1244Crossref (374) Recently, substudy high short-term mortality.11Guedeney Barthélémy Zeitouni Hauguel-Moreau Hage Kerneis Lattuca Overtchouk Rouanet de Thiele infarct-related shock: insights trial.JACC 1198-1206Crossref (9) role culprit lesion thought determined previous studies.12Farhan Vogel Waha-Thiele Ouarrak Association location vs post hoc randomized trial.JAMA 1329-1337Crossref (2) 13Sabell Banaszewski Tolppanen Jäntti Kataja Hongisto Køber Parissis Tarvasmäki findings, procedural success, timing shock.ESC Heart Fail. 7: 768-773Crossref (3) 14Fuernau Fengler Eitel Olbrich HG Hennersdorf Empen Jung Böhm Pöss Strasser RH Schuler Werdan Culprit IABP-SHOCK II-trial.Clin Res 105: 1030-1041Crossref (12) We postulated different non-culprit (ncul-SS) aimed evaluate predictors From January 2010 December 2019, presenting collected analyzed retrospectively, registry cardiovascular center Gyeongsang National University Hospital. approved institutional review board (IRB 2017-10-016). All enrolled presented chest pain lasting at least 10 min within 12 h 0.2 mV two or consecutive leads. CS defined as systolic pressure <90 mmHg 60 min, need supportive devices, inotropic agents maintain mean >65 mmHg, urine output <30 mL/h. who experienced hypotension before PCI lasted 1 exclude temporary reperfusion. Among [n=251 (14.4%)], those refused undergo PCI, having inappropriate incomplete images, vasospasm, myocarditis, bundle branch block without stenosis artery, aortic dissection, onset time over also excluded. flowchart shown Figure 1. records eligible obtained electronic medical charts. tests performed emergency room. Catecholamine, intra-aortic balloon pulsation, extracorporeal membrane oxygenation decided discretion each cardiologist. Patients underwent cardiopulmonary resuscitation included. Left ventricular ejection fraction measured 48 echocardiography biplane methods. general method current guidelines.15O'Gara PT Kushner FG Ascheim DD Casey DE Chung MK Lemos JA Ettinger SM Fang JC Fesmire FM Franklin BA Granger CB Krumholz HM Linderbaum Morrow DA Newby LK Ornato JP Ou Radford MJ Tamis-Holland JE Tommaso CL Tracy CM Woo YJ Zhao DX American College Cardiology Foundation, Task Force Practice Guidelines, Emergency Physicians, Society Cardiovascular Angiography Interventions2013 ACCF/AHA guideline management ST-elevation executive summary: Foundation/American Guidelines: developed collaboration Physicians Interventions.Catheter 2013; 82: E1-27PubMed Scholar,16Windecker Kolh Alfonso Collet J-P Cremer Falk V Filippatos Hamm Head SJ Jüni Kastrati Knuuti Laufer Richter DJ Schauerte Sousa Uva Stefanini GG Taggart DP Torracca Valgimigli Wijns Witkowski Authors/Task members2014 ESC/EACTS Guidelines revascularization: Myocardial Revascularization European (ESC) Cardio-Thoracic (EACTS)Developed special contribution Interventions (EAPCI).Eur J. 35: 2541-2619Crossref (3734) Preferences procedure methods, such route puncture, stent types, balloons, aspiration thrombectomy, clinician throughout indexed PCI. grade all before, during, procedure. classified 0 (complete occlusion), (no distal perfusion), 2 (dilated 3 (normal flow). study, images angiography unknown information model 17 segments reviewed blindly cardiologists.1Sianos assessed using pre-PCI (diagnostic) images. website tutorial (www.syntaxscore.com/calculator/start.htm), case example how calculate 2. lesions (≥50%) vessels diameter >1.5 mm scored, consensus cardiologists, angiography, electrocardiogram, echocardiography. Cul-SS achieved same algorithm. Completely occluded scored occlusion. Distal recovery scored. Interobserver reliability calculated estimate consistency measurements raters. intraclass correlation coefficient 0.913 Cohen's kappa measuring inter-rater agreement 0.711 0.001). Continuous variables are ± standard deviation median first third interquartile range. Student's t-test Mann-Whitney U-test according normal distribution. Categorical Pearson's chi-square Fisher's exact test. descriptions frequencies percentages. continuous ROC determine cut-off point mortality, then used points univariate analysis. values Youden method, statistical decide optimal values.17Youden WJ Index rating diagnostic tests.Cancer. 1950; 3: 32-35Crossref (6259) mentioned below Table 3. With values, logistic regressions seek adjusted analyses divided into models ≥22. Pairwise curve comparison predictability cul-SS, ncul-SS, SS.18DeLong ER DeLong DM Clarke-Pearson DL Comparing areas under correlated receiver operating characteristic curves: nonparametric approach.Biometrics. 1988; 44: 837Crossref (12585) variable Model done dichotomous cutoff Model2. whether add-on effect factors contents. Statistical significance set 0.05. SPSS version 21 (Chicago, USA) MedCalc 17.6 (MedCalc Software Ltd., Belgium) study. CS-STEMI, died hospital. Age, sex, history difference non-survivors. For laboratory non-survivors lower heart rate, proportion cardiac resuscitation, frequent use catecholamines mechanical support, glomerular filtration hemoglobin levels, glucose carbon dioxide content, when (Table 1). echocardiography, 39 (49.4%) available subjects non-survivor group did perform terms stenotic arteries (≥50%), arteries, chronic occlusion groups. non-survivors, frequently located right phenomena less achievements grades 2–3 1).Table 1Baseline characteristicsVariableSurvivors (n=136)Nonsurvivors (n=79)p-valueMen100 (73.5%)53 (67.1%)0.350Age (years)68±1372±140.098Body mass (kg/m2)23±424±60.618Systolic (mmHg)80±3854±440.000Heart (bpm)64±3850±440.017Left ventricle (%)*Only undergone transthoracic echocardiography.50±1144±160.037Hypertension68 (50.0%)35 (44.3%)0.480Diabetes mellitus35 (25.7%)21 (26.6%)1.000Ex-smoker/current94 (69.1%)44 (55.7%)0.115Prior PCI10 (7.4%)7 (8.9%)0.794Prior infarction11 (8.1%)6 (7.6%)1.000Prior ischemic stroke10 (7.4%)6 (7.6%)1.000Cardiopulmonary resuscitation33 (24.3%)44 (55.7%)0.000Use catecholamines111 (84.1%)78 (98.7%)0.000Extracorporeal oxygenation6 (4.4%)22 (27.8%)0.000Intra-aortic pump24 (17.6%)23 (29.1%)0.060Arrhythmia Complete atrioventricular block42 (30.9%)15 (19.0%)0.077 Ventricular fibrillation tachycardia45 (33.1%)34 (43.0%)0.186 Pulseless electrical activity0 (0.0%)3 (3.8%)0.048§The statistic pulseless activity computed Exact test, because cells (50.0%) expected counts 5 (1.9 1.1, respectively) × table. Hemoglobin (g/L)13±212±20.001Glomerular rate†Glomerular MDRD equation.(ml/min/1.73m2)65±2352±220.000 Serum (mg/dL)228±100299±1350.000 Blood (mEq/L)18±515±50.000 Troponin-I (initial) (ng/dL)4.4±14.37.7±17.20.143 A1c (%)6.3±1.26.5±1.30.226Number narrowed arteries‡The narrowing lumen ≥50% intravascular ultrasound optical coherence tomography.1.9±0.82.0±0.80.471 158 (42.6%)27 (34.2%) 238 (27.9%)25 (31.6%) 340 (29.4%)27 (34.2%)Infarct-related main6 (4.4%)8 (10.1%)0.149 anterior descending41 (30.1%)31 (39.2%)0.181 circumflex12 (8.8%)6 (7.6%)0.805 Right77 (56.5%)33 (41.8%)0.047Symptom-to-balloon (min)156 (108-277)152 (105-250)0.735Door-to-balloon (min)50 (40-61)60 (48-78)0.563Aspiration thrombectomy70 (51.5%)38 (48.1%)0.673Chronic (number)0.119 0118 (86.8%)62 (78.5%) ≥118 (13.2%)17 (21.5%)TIMI – pre0.548 082 (60.3%)53 (67.1%) 115 (11.0%)6 (7.6%) 213 (9.6%)5 (6.3%) 326 (19.1%)15 (19.0%)TIMI post0.047 03 (2.2%)2 (2.5%) 13 (2.2%)6 (11.0%)14 (17.7%) 3115 (84.6%)57 (72.2%)No-reflow phenomenon27 (19.9%)30 (38.0%)0.006Second-stage PCI20 (14.7%)6 (7.6%)0.135The procedure1.1±0.31.2±0.40.117Presence collateral circulation artery∥Fisher's test analyze it due cell count category. intervention; infarction.5 (3.7%)3 (3.8%)0.964 Only echocardiography.§ table.† Glomerular equation.‡ tomography.∥ category.PCI infarction. Open table new tab patients’ characteristics 11 (Supplementary infarction, catecholamines, third-degree block. Remarkably, descending circumflex incidences <11 group. but intermediate (SS ≥ 22) larger survivors. significantly ncul-SS differ both groups 2). According subgroup disease. single- diseases. Using Pearson coefficient, weak observed (R2 0.318, strong 0.579, (Figure 3). No ncul-SS.Table 2SYNTAX non-survivorsVariableSurvivors (n=79)p-valueSYNTAX (mean SD)*SYNTAX sum score. any responsible infarction.23±1125±120.152 Low (≤22)77 (56.6%)32 (40.5%)0.051 Intermediate (22–33)30 (22.1%)25 High (≥33)29 (21.3%)22 (27.8%) 2259 (43.4%)47 (59.5%)0.023Culprit SD)12±715±80.035 ≥1149 (36.0%)47 (59.5%)0.001Non-culprit SD)10±1011±100.868SYNTAX sorted vessel diseaseOne-vessel (n=85)n=58n=27 2211 (19.0%)8 (29.6%)0.272 ≥1124 (41.4%)11 (40.7%)0.956Two-vessel (n=63)n=38n=25 2222 (57.9%)17 (68.0%)0.419 ≥1118 (47.4%)19 (76.0%)0.024Three-vessel (n=67)n=40n=27 2226 (65.0%)22 (81.5%)0.142 ≥1117 (42.5%)20 (74.1%)0.011Multi-vessel (n=130)n=78n=52 2248 (36.9%)39 (75.0%)0.110 ≥1135 (44.9%)39 (75.0%)0.001cul-SS culprit-SYNTAX angiography-derived post-PCI grade, presence SS, predictor regression adjusting multiple moderate limited (AUC 0.617 2, 0.60 sensitivity specificity 60% 64%, respectively. Interestingly, adding (no-reflow ≤2) metabolic derangement parameter (CO2 15 mmol/L) power increased 3, 62% 74% 4).Table 3Binary predict mortalityUnadjusted modelAdjusted modelVariablesOR95% CIp-valueOR95% CIp-valueClinical Systolic <78 mmHg*systolic (63, 61, 0.655, 0.255 0.001)2.701.52–4.790.003.11.48–6.420.003 Cardiopulmonary resuscitation3.942.17–7.090.002.61.20–5.590.016 Use catecholamines14.81.94–1120.005.80.70–48.90.103 <12 g/L†hemoglobin g/dL (49, 74, 0.639 0.001)2.711.51–4.850.012.31.04–4.910.040 <48 mL/min/1.73 m2‡estimated (53, 77, 0.667 0.001)3.812.09–6.940.002.31.05–5.130.037 Glucose ≥267 mg/dL§serum mg/dL (54, 75, 0.668 0.001)3.451.92–6.200.001.80.88–4.040.104 mmol/L∥total contents (60, 72, 0.705 0.001),3.792.11–6.800.001.70.76–3.700.198With (model 1) ≤22.11.07–4.160.031.30.47–3.700.601 No-reflow phenomenon2.31.24–4.190.011.80.70–4.590.226 ≥11¶cul-SS 65, 0.600 0.014) and2.31.27–3.980.012.71.30–5.700.008With 2) ≤22.11.07–4.160.031.40.51–3.930.505 phenomenon2.31.24–4.190.011.70.67–4.430.255 ≥22⁎⁎SYNTAX 22 57, 0.569 0.096)1.91.09–3.370.0231.80.86–3.740.118cul-SS score; infarction.Models including aforementioned factors, respectively, binary analyses.The 0.05 determined, built Medicalc software. sensitivity, specificity, p-value displayed order: 0.001)† 0.001)‡ estimated 0.001)§ serum 0.001)∥ 0.001),¶ 0.096) 4Pairwise curves deathAUC95% CIp-valuep-value comparisonModel score0.5690.49–0.650.0900.356 cul-SS0.6170.53–0.670.090Reference ncul-SS0.5100.43–0.590.8020.118Model ≥220.5810.50–0.660.0490.250 ≥110.6000.52–0.680.015Reference >100.5390.47–0.610.2640.090Model + ≤20.6300.55–0.710.0020.864 reflow0.6560.58–0.730.0000.016 ≤2 reflow0.6610.59–0.740.0000.010 <150.6770.61–0.750.0000.009 reflow <150.7450.68–0.810.0000.001cul-SS Models analyses. ncul-SS. found most potent population. SS. Furthermore, could Although evidence-based treatment hand.19Thiele Ohman EM Management update 2019.Eur 40: 2671-2683Crossref Scholar,20Hochman JS Sleeper Webb JG Sanborn TA White HD Talley JD Buller Jacobs AK Slater JN Col McKinlay LeJemtel TH Early complicated shock. SHOCK InvestigatorsShould we emergently revascularize coronaries 1999; 341: 625-634PubMed randomized, multicenter trial benefit renal outcome.9Thiele Scholar,21Thiele Jobs Hunziker InvestigatorsOne-year 2018; 379: 1699-1710Crossref (179) Culprit-only accepted 2018 guideline.22Neumann F-J Sousa-Uva Ahlsson Banning Benedetto Byrne RA Koller Kristensen SD Niebauer Seferovic PM Sibbing Yadav Zembala MO ESC Scientific Document Group2018 revascularization.Eur 40. 2019: 87-165Google CS.10Smits widely measure burden few reports CS. small population (N 61) mortality.7Javanainen 624) outcome.11Guedeney Scholar,23Barthélémy Brugier Vignolles Bertin Guedeney Vicaut G. Predictive shock.J 2021; 77: 144-155Crossref (10) range wider (median 22, 3–60), though Unfortunately, its lost factors. Previously, Intraaortic Balloon Pump Shock II (IABP-SHOCK II) trial14Fuernau show association worse outcome, inconsistent pathophysiologic concept.24Backhaus Kowallick JT Stiermaier Lange Koschalka Navarra J-L Lotz Kutty Bigalke Gutberlet Feistritzer H-J Hasenfuß Schuster I. vessel-related mechanics implications followingacute infarction.Clin 109: 339-349Crossref (13) CardShock substudy13Sabell these studies, analysis12Farhan proximal rates others survivor To prognosis, dominance myocardium risk, successful should considered, reflected cul-SS. itself moderate, flow, no-reflow, importance well-evaluated.13Sabell Scholar,25Danin P-E Siegenthaler Levraut Bernardin Dellamonica Bendjelid K. Monitoring states.J Clin Monit Comput. 2015; 29: 591-600Crossref (7) biomarker tissue hypoxemia instead arterial lactate about shock.25Danin contemporary era, well-validated, risk comprised six factors: age, stroke, glucose, creatinine, lactate. analysis, included score.26Pöss Köster Risk stratification infarction.J 69: 1913-1920Crossref (149) (lactate replaced study) applied Our following limitations. First, this retrospective, nonrandomized, single-center selection bias own unmeasured bias. Second, sustained low hence cannot represent Third, possibility complications cause half non-survivor. feature failure. Fourth, reflect targeted fresh easy guidewire passage. Lastly, one-vessel 40%, may affected prognosis. superior combinations content. Nothing. Download .docx (.02 MB) Help docx files