Thiele H, Akin I, Sandri M et al. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017 Dec 21;377(25):2419-2432.
Pablo Avanzas. Professor of Medicine. Universidad de Oviedo. Consultant in Interventional Cardiology. Hospital Universitario Central de Asturias, Spain
The mortality associated with cardiogenic shock in acute myocardial infarction can be reduced with the use of early revascularization, predominantly percutaneous coronary intervention (PCI), to restore blood flow to the culprit coronary artery. Up to 80% of patients who have cardiogenic shock present with multivessel coronary artery disease, and mortality is higher with multivessel disease than with single-vessel disease. The value of performing immediate PCI for clinically important stenoses of major nonculprit coronary arteries is controversial.
The Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was designed to test the hypothesis that PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, would result in better clinical outcomes than immediate multivessel PCI among patients who have multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock. In this randomized, multicenter trial involving 706 patients, PCI of the culprit lesion only (with the option of staged revascularization of nonculprit lesions) was superior to immediate multivessel PCI with respect to a composite end point of death or renal-replacement therapy at 30 days. The difference was driven mainly by significantly lower mortality in the culprit-lesion-only PCI group.
Nearly two decades ago, the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial established that mortality was lower with emergency revascularization than with initial medical stabilization and selective delayed revascularization in patients with ST-segment elevation myocardial infarction (STEMI). In the SHOCK trial, PCI of the culprit lesion only was the most common therapy for initial revascularization. Although more complete revascularization might have been expected to have an increased benefit, the small subgroup that underwent initial multivessel PCI had higher mortality than the subgroup that underwent culprit-lesion-only PCI. A meta-analysis of 10 cohort studies, which included a total of 6051 patients with cardiogenic shock, also showed higher early mortality with multivessel PCI than with culprit-lesion-only PCI.
The CULPRIT-SHOCK trial provides compelling evidence that a strategy of culprit-lesion-only PCI is preferred over initial multivessel PCI for patients with cardiogenic shock. These findings are discordant with the results of a meta-analysis of randomized trials that included patients with uncomplicated STEMI, which showed a lower rate of a composite of death or myocardial infarction with initial multivessel PCI than with culprit-lesion-only PCI. These disparate findings suggest that patients with cardiogenic shock may be at an increased risk for adverse outcomes during complex multivessel PCI procedures. The potential mechanisms of this increased risk remain speculative. Despite major advances in PCI technique and antithrombotic pharmacology during the approximately 20 years between the SHOCK trial and the CULPRIT-SHOCK trial, 30-day mortality among patients who underwent initial culprit-lesion-only PCI was nearly identical in the two trials (approximately 45%). Additional trials are warranted to test strategies that may further reduce mortality