CULPRIT-SHOCK Results Will Transform Guidelines and Clinical Practice

 Courtesy of the SBHCI.

After treating the culprit lesion in patients with acute myocardial infarction complicated by cardiogenic shock, continuing revascularization of all other lesions worsens outcomes. This finding of the CULPRIT-SHOCK trial has changed entirely the way we treated this patient group and will surely modify guidelines.

Culprit-lesion treatment with the option to perform staged revascularization of nonculprit lesions lowers the composite endpoint of death and severe renal failure within 30 days of randomization (45.9% vs. 55.4%; relative risk [RR]: 0.83; 95% confidence interval [CI]: 0.71-0.96).

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Such difference was unexpectedly driven primarily by a reduction in all-cause mortality (43.3% vs. 51.6%; RR: 0.84; 95% CI: 0.72-0.98), instead of a significant reduction in severe renal failure (which actually showed no differences).

The message seems to be clear: in such complex patients, keep it as simple as possible.

Currently, European guidelines contain a recommendation to perform angioplasty of all other lesions after treating the culprit lesion. This study, published simultaneously in the New England Journal of Medicine, is poised to change everything, including guidelines.

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The CULPRIT-SHOCK trial was conducted at 83 European centers and enrolled 706 patients with multivessel disease, acute myocardial infarction (with or without ST-elevation), and cardiogenic shock. These subjects were randomized to treatment of the culprit lesion only, with an option for staged revascularization of nonculprit lesions, or to multivessel treatment during the index procedure.

In the culprit-only arm, 17.7% of patients underwent staged revascularization, while 12.5% of patients crossed over and ultimately underwent multivessel angioplasty. In the complete revascularization group, 9.4% of patients crossed over and underwent angioplasty only in the culprit artery.

The reduction in the primary endpoint was similar in intention-to-treat, per-protocol, and as-treated analyses.

Other endpoints such as recurrent infarction, readmission for heart failure, bleeding, or stroke were similar between trial arms.

 Courtesy of the SBHCI.

Original title: PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock.

Presenter: Thiele H.

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