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Coronary Revascularization Strategies in Patients with MI, Multi-vessel CAD, and Cardiogenic Shock (CS)

Shock is associated with high mortality.

Emergency revascularization for CS has improved survival. However, the 35-45% 30-day mortality rate with PCI has persisted for decades despite advances in anti-thrombotic pharmacology and PCI techniques.

Multi-vessel PCI is associated with worse outcomes in MI and cardiogenic shock.

In the CULPRIT-SHOCK study of patients with acute MI, multi-vessel coronary artery disease, and CS, the 30-day risk of a composite of death or severe renal failure was higher among those who underwent multi-vessel PCI in comparison to infarct-artery PCI only. Trials are warranted to test novel strategies that may reduce mortality in patients with MI, multi-vessel CAD, and CS.

Non-randomized data suggest potential benefit from complete revascularization and cardioprotective measures employed with CABG in patients with multi-vessel CAD and CS.

We are in the early stages of planning a randomized trial of initial infarct-only PCI versus multi-vessel CABG with/without IRA reperfusion (mechanical thrombectomy and/or POBA) in patients with MI, multi-vessel CAD, and CS. Your responses to the questions below will help to guide study design.

Please select your specialty / training:

* must provide value

Years in Practice:

Please select your practice setting:

* must provide value

Please provide your hospital affiliation:

Please provide the location of your hospital (city / country):

May we contact you if we have follow-up queries based on your responses?

Yes No

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Please provide your name

Please provide your e-mail address:

Please provide your telephone number:

Is there an advanced heart failure mechanical circulatory support program at your institution?

Yes No

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Mechanical circulatory support program director name:

Mechanical circulatory support program director e-mail address:

Mechanical circulatory support program director telephone number:

Is there a heart failure sub-specialist at your institution?

Yes No

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Heart failure program director name:

Heart failure program director e-mail address:

Heart failure program director telephone number:

How many patients with STEMI does your center treat each year?

How many patients with MI (STEMI or NSTEMI) complicated by cardiogenic shock does your center treat each year?

Of these, how many patients with MI and cardiogenic shock have multi-vessel CAD?

What is the standard approach to revascularization in a patient with acute MI with cardiogenic shock and multivessel disease at your center?

What revascularization strategy do you believe is associated with the best outcomes in AMI with cardiogenic shock and multivessel CAD?

In patients with MI, cardiogenic shock, and multivessel disease undergoing revascularization by PCI, what is the preferred method of mechanical circulatory support at your center?

You selected "Other". Please specify the preferred method of MCS at your center:

Is there a minimum lactate threshold for which you would consider placement of a mechanical circulatory support device (other than IABP)?

Yes No

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What is the minimum lactate threshold for mechanical circulatory support (other than IABP)?

In patients with residual cardiogenic shock after PCI, which of the following interventions do you most commonly use for circulatory / hemodynamic support? (Check all that apply)

Norepinephrine

Vasopressin

Phenylephrine

Epinephrine

Dopamine

Dobutamine

Milrinone

LVAD / BiVAD

ECMO

Impella

IABP

Other MCS

Does your center have an algorithm for the stepwise escalation of hemodynamic / circulatory support post-PCI?

Yes

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Please describe this algorithm:

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How many cardiac surgeons operate at your hospital center?

How many CABG surgeries are performed at your hospital center each year?

If you were to refer a patient with AMI complicated by cardiogenic shock with multivessel CAD for CABG (without performing balloon angioplasty of the infarct vessel at the time of angiography), what length of time delay to the OR would you consider to be acceptable?

Do you think your center could achieve this target?

Yes No

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Why would your center have difficulty achieving this target time to CABG?

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If you were to refer a patient with AMI complicated by cardiogenic shock with multivessel CAD for CABG, after BALLOON ANGIOPLASTY of the INFARCT RELATED ARTERY was performed to re-establish coronary flow prior to surgery, what length of time delay to the OR would you consider to be acceptable?

Do you think your center could achieve this target?

Yes No

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Why would your center have difficulty achieving this target time to CABG?

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In patients with MI, cardiogenic shock, and multivessel disease undergoing revascularization by CABG, what is the preferred method of mechanical circulatory support at your center?

You selected "Other". Please specify the preferred method of MCS at your center:

Is there a minimum lactate threshold for which you would consider placement of a mechanical circulatory support device (other than IABP)?

Yes No

reset

What is the minimum lactate threshold for which you would consider placement of mechanical circulatory support (other than IABP)?

In patients with residual cardiogenic shock after CABG, which of the following interventions do you most commonly use for circulatory / hemodynamic support? (Check all that apply)

Norepinephrine

Vasopressin

Phenylephrine

Epinephrine

Dopamine

Dobutamine

Milrinone

LVAD / BiVAD

ECMO

Impella

Other MCS

IABP

Does your center have an algorithm for the stepwise escalation of hemodynamic / circulatory support after CABG?

Yes

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Please describe this algorithm:

Expand

Would you be willing to enroll patients with AMI with multivessel CAD and cardiogenic shock into a RANDOMIZED trial of: IRA-PCI (with or without staged complete revascularization) versus emergent multivessel CABG with intent to perform complete revascularization?

Yes No

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What are the major barriers to participation?

Insufficient number of eligible cases

IRB unwilling to approve protocol

Difficulty with recruitment / identifying cases

Difficulty obtaining informed consent

Interventional cardiologists unwilling to support trial

Cardiac surgeons unwilling to support trial

Delays to emergency CABG

Not scientifically interesting

What aspects of the trial design would affect your willingness to participate / enroll patients? (Optional)

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Please provide any additional thoughts, concerns, or suggestions: (Optional)

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May we include your responses to this survey in a prospective observational research study on contemporary approaches to management of cardiogenic shock?

* must provide value

Yes

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The purpose of this research study is to determine the contemporary clinical management of patients with myocardial infarction, multi-vessel coronary artery disease, and cardiogenic shock. We are asking you to take part in this research study because you may care for patients with this condition. Participating in this study requires approximately 10 minutes of time and involves completing a short electronic survey. You are free to skip any questions that you prefer not to answer. No follow-up is required. There may be some risk from being in this study. You may experience frustration that is often experienced when completing surveys. However, such risks are not viewed as being in excess of "minimal risk". There are no other foreseeable risks to participation in this study. You will not benefit personally from participating in this study. However, we hope that the results of the survey may provide a better understanding of current practice patterns in the management of cardiogenic shock. Participation in this study is completely voluntary and you may choose to not participate in this research study, even if you have already provided answers to the survey questions. You will not be paid for being in this study. There will be no cost to you for being in this research study. Any identifiable information you choose to provide will not be used for the purposes of the research study. If you decide to participate, you are free to leave the study at any time. To withdraw your permission, send a written notice to the principal investigator for the study: Dr. Nathaniel Smilowitz (Division of Cardiology, Department of Medicine, 530 First Avenue, New York, NY, USA 10016. Tel: 212-263-5656).

If you have questions, concerns or complaints regarding your participation in this research study or if you have any questions about your rights as a research subject, you should speak with the Principal Investigator listed above. If a member of the research team cannot be reached or you want to talk to someone other than those working on the study, you may contact the New York University School of Medicine Institutional Review Board (IRB) at (212) 263-4110.

I acknowledge I have read the above statement and I wish to participate in the research study.

I do not wish to participate in the research study.

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.