Impact of intracoronary imaging-guided percutaneous coronary intervention on procedural outcomes among patients with cardiogenic shock
Authors: Mohamed M , Kinnaird T , Rab T , Zaman S , Banerjee A , Sirker A , Mintz G , Mamas M 
Published: November 2023

Abstract

Background
Intracoronary imaging (ICI), including intravascular ultrasound (IVUS) or optical coherence tomography (OCT), is known to correlate with a reduction in rates of cardiac death after percutaneous coronary intervention (PCI), driven by lower rates of reinfarction and stent thrombosis. [1,2] However, there are limited data around its utility amongst patients with acute coronary syndrome (ACS) and cardiogenic shock, who are inherently at a high risk of stent thrombosis.

Aims
To examine the frequency of utilisation of ICI among ACS patients with cardiogenic shock, and their subsequent outcomes, in a national cohort of PCI procedures over a six-year period.

Methods
All PCI procedures for ACS patients with cardiogenic shock in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and non-ICI groups. Multivariable logistic regression analyses were performed to examine the odds of in-hospital major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding (BARC 3-5) in the ICI-guided group, compared with the non-ICI group, as well as predictors of receipt of ICI-guided PCI.

Results
Of 15,738 PCI procedures performed between 2014 and 2020, 1,240 procedures (7.9%) were ICI-guided. Overall, the rate of ICI use amongst those with cardiogenic shock has more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST elevation ACS and stent thrombosis. The rate of MACCE was significantly lower in the ICI-guided group compared with the non-ICI group (29.8% vs. 38.2%, p&lt;0.001), driven by lower rate of all-cause mortality (28.6% vs. 37.0%, p&lt;0.001). (Figure 1) There were no differences for other secondary outcomes between groups. In multivariable analysis, the odds of MACCE and all-cause mortality in those undergoing ICI-guided PCI remained significantly lower than in the non-ICI group (OR 0.65 95% CI 0.56, 0.76 and OR 0.65 95% CI 0.55, 0.75, respectively, p&lt;0.001 for both). (Figure 2). Advanced age (OR 0.98) and STEMI presentation (OR 0.54) negatively correlated with ICI use while stent thrombosis presentation (OR 2.66), previous PCI (OR 2.02), intervention on LMS (OR 4.19) and proximal LAD lesions (OR 1.62) and need for calcium modification (OR 2.13) positively correlated with increased ICI use.

Conclusion
The utilisation of ICI among patients with cardiogenic shock has more than doubled over a 6-year period on a national level but remains significantly under-utilised, with less than 1-in-6 patients in receipt of ICI-guided PCI in 2020. ICI use is associated with a prognostic benefit in terms of reduction of in-hospital MACCE and all-cause mortality in this high-risk patient group and should be more frequently utilised to increase their long-term survival.Figure 1.In-hospital crude outcomesFigure 1B.Adjusted odds ratios (OR)