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CULPRIT-SHOCK

Clinical Question

In patients with acute myocardial infarction, cardiogenic shock, and multivessel disease, is immediate PCI of the culprit lesion only superior to immediate multivessel PCI?

Bottom Line

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.

Major Points

Guidelines

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.

Design

Multicenter, randomized, open-label trial comparing two initial revascularization strategies: culprit-lesion-only PCI (with staged revascularization option) versus immediate multivessel PCI.

Population

706 patients with acute MI, cardiogenic shock, and multivessel disease.

Interventions

- 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.

Outcomes

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).

Secondary Outcomes:
- 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.

Criticisms

- 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.

Funding

Funded by the European Union 7th Framework Program, German Heart Research Foundation, and German Cardiac Society.