PCI of culprit lesion alone compared with multivessel PCI results in fewer deaths in AMI with cardiogenic shock

Reference

Thiele H, Akin I, Sandri G, et al, for the CULPRIT-SHOCK Investigators. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med 2017 Oct 30 [Epub ahead of print]

Synopsis

Patients with AMI with cardiogenic shock and multivessel coronary artery disease with an identifiable culprit lesion were randomized to receive either PCI of the culprit lesion only (n = 351) or immediate multivessel PCI (n = 355). The 2 groups had similar characteristics and analysis was by intention to treat. There was 12.5% crossover from the culprit-lesion-only group to the multivessel group and 9.4% crossover from the multivessel group to culprit-lesion-only group. Overall, 18% of the patients in the culprit-lesion-only group underwent staged revascularization following the initial procedure. The multivessel PCI group received a higher dose of contrast and spent more time under fluoroscopy. Data were analyzed from 344 patients in the culprit-lesion-only group and from 342 patients in the multivessel PCI group. The rate of the primary outcome—the composite of death or severe renal failure leading renal-replacement therapy within 30 days—was decreased in the culprit-lesion-only group as compared with the multivessel PCI group (46% vs 55%; relative risk [RR] 0.83; 95% CI 0.71 - 0.96; P = .01). Results were similar in the per-protocol analysis. The difference in the 2 groups was driven primarily by fewer deaths in the culprit-lesion-only group (43% vs 52%; RR 0.83; 0.72 - 0.98; P = .03). You would have to treat 12 patients with the culprit lesion approach to prevent one death. The authors postulate that the lack of benefit from immediate multivessel PCI may be due to increased contrast load leading to volume overload, and a longer procedure time leading to further compromise of an already hemodynamically unstable patient.