PCI strategies in patients with acute myocardial infarction and cardiogenic shock
Selected in the New England Journal of Medicine by G. Di Gioia
Holger Thiele, Ibrahim Akin, Marcus Sandri, Georg Fuernau, Suzanne de Waha, Roza Meyer-Saraei, Peter Nordbeck, Tobias Geisler, Ulf Landmesser, Carsten Skurk, Andreas Fach, Harald Lapp, Jan J. Piek, Marko Noc, Tomaž Goslar, Stephan B. Felix, Lars S. Maier, Janina Stepinska, Keith Oldroyd, Pranas Serpytis, Gilles Montalescot, Olivier Barthelemy, Kurt Huber, Stephan Windecker, Stefano Savonitto, Patrizia Torremante, Christiaan Vrints, Steffen Schneider, Steffen Desch, and Uwe Zeymer, for the CULPRIT-SHOCK Investigators
N Engl J Med. 2017 Oct 30 [Epub ahead of print]
LinkRead the abstract
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Why this study – the rationale/objective?
Most of the patients presenting with cardiogenic shock and myocardial infarction have a multivessel disease. Current guidelines recommend trying to treat all significant lesions in these patients. However, poor evidence in this clinical setting makes revascularization decisions very controversial.
How was it executed – the methodology?
In this multicenter trial, 706 patients with acute myocardial infarction and multivessel coronary disease presenting with cardiogenic shock were randomly assigned either to PCI of the culprit only artery (with the chance to perform a staged PCI of the untreated lesions) or to PCI of all significant lesions. The primary endpoint was a composite of death and renal failure requiring replacement therapy at 30 days.
What is the main result?
The primary endpoint occurred significantly less frequently in the culprit-lesion-only PCI group than in the multivessel PCI group (45.9% vs 55.4% of patients; p = 0.01). This result was mostly due to significantly lower mortality (43.3% vs. 51.6%; p = 0.03) in the first group. Nevertheless, there was a trend towards lower incidence of renal failure in the culprit-lesion-only PCI group as compared with the multivessel PCI group (11.6% vs. 16.4%; p = 0.07).
Critical reading and the relevance for clinical practice
During the last few years, we have witnessed a bidirectional switch in the direction of the evidence in the setting of STEMI. Actually, in patients presenting without cardiogenic shock, culprit-lesion only PCI used to be an almost carved in stone practice rule.
Recent studies, though, albeit disputable, have shown that complete revascularization at the time of primary PCI could be even beneficial as opposed to culprit-lesion-only PCI. On the other hand, in patients presenting with cardiogenic shock complete revascularization of all significant lesions was recommended.
The present study seems to tear down also this faint certainty. Indeed, in this study, a 10% lower incidence of the primary endpoint was observed when only the culprit lesion was treated. This result was mainly led by lower all-cause mortality, although there was a trend also toward a lower incidence of renal replacement therapy.
Conducting randomized trials in emergency settings such as a cardiogenic shock is very hard and it is almost impossible to ensure that the enormous amount of variables (i.e. medical therapy, anaesthesiologic support) do not affect the final result.
Notwithstanding, this trial represents a welcome injection of common sense and caution when facing cardiogenic shock, and the conspicuous rate of crossover between the two arms of the study makes room for the necessities and the instincts of the operator. However, the fact that mortality in cardiogenic shock has not changed one bit during the last 20 years is something we should all reflect upon. Serious efforts in finding a game-changing therapeutic strategy for this dire condition should be the goal of future research.