Best of heart failure

31 Here, investigators randomly assigned 706 patients who had multivessel dis- ease, acute myocardial infarction, and CS to one of two initial revascularization strategies: either culprit-lesion-only PCI with the option of staged revasculari- zation of non-culprit lesions or immediate multivessel PCI. The primary end- point was a composite of death or renal failure leading to renal-replacement therapy within 30 days after randomization. Safety endpoints included bleed- ing and stroke. At 30 days, the composite primary endpoint occurred in 45.9% of subjects in the culprit-lesion-only PCI group and 55.4% in the multivessel PCI group (relative risk [RR], 0.83; 95% CI, 0.71 to 0.96; p = 0.01). The RR of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; p = 0.03) and for renal replacement therapy was 0.71 (95% CI, 0.49 to 1.03; p = 0.07) [ 17 •• ]. Furthermore, data on 1-year follow-up were recently published by the same investigators, affirming the benefits of culprit-vessel-only PCI in patients presenting with AMI-CS. At 1 year, death had occurred in 50.0% of patients in the culprit-lesion-only PCI group compared to 56.9% in the multivessel PCI group (RR, 0.88; 95% CI, 0.76 to 1.01) (Fig. 3 ). The rate of recurrent infarction was 1.7% with culprit- lesion-only PCI and 2.1% with multivessel PCI (RR, 0.85; 95% CI, 0.29 to 2.50), and the rate of a composite of death or recurrent infarction was 50.9% and 58.4%, respectively (RR, 0.87; 95% CI, 0.76 to 1.00). Impor- tantly, repeat revascularization occurred more frequently in patients ini- tially randomized to culprit-lesion-only PCI than in patients with multivessel PCI (32.3% vs. 9.4%; RR, 3.44; 95% CI, 2.39 to 4.95), as did rehospitalization for heart failure (5.2% vs. 1.2%; RR, 4.46; 95% CI, 1.53 to 13.04) [ 18 •• ]. With percutaneously delivered AMCS increasingly available, this paradigm may begin to change in patients with CS. Ventricular unloading and systemic circulatory support may be initiated by experienced operators even before achieving effective restoration of coronary flow. While the door-to-balloon time continues to be important for ST-elevation MI not complicated by CS, opti- mizing systemic circulation and organ perfusion in patients with CS appears to be as or more important than immediately opening an occluded vessel in order to avoid hemo-metabolic shock [ 19 ]. Timely initiation of AMCS, or the “ door- to-unload time ” (DTU), may be a key determinant of outcomes in patient presenting with CS [ 20 ]. Preliminary data from the Detroit Shock Initiative to treat AMI-CS has shown improving survival rates by up to 65%. Here, clinicians utilized a standardized protocol for patients presenting with AMI-CS, including but not limited to mechanical unloading using the Impella CP, a catheter- mounted trans-valvular axial flow pump, prior to primary PCI [ 21 ]. Although more appropriately powered and randomized data are required, our current level of knowledge seems to support prompt and proper initiation of AMCS in patients presenting with AMI-CS. Revascularization in patients with advanced heart failure and patients on durable mechanical circulatory support devices It is important to differentiate patients who are “ crashing, burning, or sliding fast ” (INTERMACS 1 – 2) as discussed above from patients with HF who are 4 Page 6 of 12 Curr Treat Options Cardio Med (2019) 21: 4