"Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK)"
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In patients with acute myocardial infarction, cardiogenic shock, and multivessel disease, is immediate PCI of the culprit lesion only superior to immediate multivessel PCI?
In acute myocardial infarction with cardiogenic shock and multivessel disease, immediate PCI of the culprit lesion only, with optional staged revascularization of nonculprit lesions, leads to lower 30-day mortality and composite risk of death or severe renal failure requiring renal-replacement therapy when compared to immediate multivessel PCI.
Patients with cardiogenic shock associated with acute myocardial infarction (MI) often present with multivessel coronary artery disease. The CULPRIT-SHOCK trial aimed to assess whether immediate PCI targeting the culprit lesion solely, followed by optional staged revascularization, would yield more favorable outcomes than immediate multivessel PCI. The study found that performing PCI only on the culprit lesion resulted in a lower risk of death or renal-replacement therapy at 30 days than multivessel PCI. This benefit appeared to be primarily driven by reduced 30-day mortality in the culprit-lesion-only PCI group.
Current guidelines suggest immediate PCI of nonculprit lesions in patients with cardiogenic shock remains controversial and undefined, with the American and European guidelines offering differing perspectives.
Multicenter, randomized, open-label trial comparing two initial revascularization strategies: culprit-lesion-only PCI (with staged revascularization option) versus immediate multivessel PCI.
706 patients with acute MI, cardiogenic shock, and multivessel disease.
- Culprit-lesion-only PCI (n=344 analyzed): Immediate PCI of the identified culprit lesion with option for later revascularization of nonculprit lesions. - Multivessel PCI (n=341 analyzed): Immediate PCI of all stenotic coronary arteries.
Primary Outcome: - Lower composite of death or renal-replacement therapy within 30 days in culprit-lesion-only PCI group compared to multivessel PCI group (45.9% vs. 55.4%; RR 0.83; P=0.01).
- Reduced risk of death alone in culprit-lesion-only PCI group (43.3% vs. 51.6%; RR 0.84; P=0.03). - No significant difference in risk of renal-replacement therapy alone. - Rates of myocardial reinfarction, rehospitalization for congestive heart failure, bleeding, and stroke were similar across both groups.
- Open-label design without blinding, which might introduce bias. - Some patients (12.5%) in the culprit-lesion-only PCI group crossed over and received immediate multivessel PCI. - Staged revascularization was performed in a notable proportion (17.7%) of patients in the culprit-lesion-only PCI group; impacts on the measured benefit are unclear.
Funded by the European Union 7th Framework Program, German Heart Research Foundation, and German Cardiac Society.
https://clinicaltrials.gov/ct2/show/NCT01927549 Thiele H, Akin I, Sandri M, et al. N Engl J Med. 2017;epublished ahead of print.