The analysis also suggests that CABG may be preferable when complete revascularization with PCI is not possible.
The findings, reported in the American Heart Journal for January, are from a review of studies that compared CABG with PCI for this clinical indication. In searching MEDLINE, EMBASE, and other sources through June 15, 2009, Dr. Rajendra H. Mehta, from Duke Clinical Research Institute, Durham, North Carolina, and colleagues identified only three appropriate studies, all observational.
In the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial, with 152 patients randomized to early revascularization, 30-day mortality was roughly 44% with CABG or PCI. One-year mortality was also similar for each, hovering around 50%.
An analysis of the parallel SHOCK registry reported on 276 patients with cardiogenic shock related to left ventricular failure who had PCI, and another 109 who underwent CABG. In-hospital mortality was lower with CABG than with PCI: 23.9% vs. 46.4%. Further analysis indicated that a significant difference was only apparent in patients with multivessel disease.
Lastly, Dr. Mehta’s team reviewed a study that looked at in-hospital mortality trends from 1995 to 2004 for patients with cardiogenic shock complicating acute myocardial infarction. The study, which used data from the National Registry of Myocardial Infarction, found that mortality after PCI decreased significant during the study period (p < 0.001), while mortality after CABG remained stable. In recent years, in-hospital mortality after PCI held steady around 35%, whereas with CABG, rates varied widely: 30.4% in 2002, 50.0% in 2003, and 18.2% in 2004.
“Large randomized trials are needed to evaluate the relative merits of currently available revascularization strategies using newer antithrombotic agents and stents as adjunctive therapies in this patient population,” the authors conclude.
Am Heart J 2010;159:141-147.