Stenting only in culprit artery in Cardiogenic Shock-Guidelines Challenged

It is well established that early revascularization with percutaneous coronary intervention (PCI) reduces mortality after cardiogenic shock (CS) in acute myocardial infarction.Upto 80% of patients who have AMI with Carcinogenic Shock have multivessel disease and the value of performing immediate PCI for clinically important stenoses of major nonculprit arteries is controversial. Dr.Holger Thiele and colleagues conducted a randomized multicenter CULPRIT-SHOCK trial to find out whether in patients with multivessel disease and AMI with CS , PCI should be performed immediately for stenosis of the culprit lesion only or multivessel PCI was preferred for revascularization of nonculprit lesions also.They concluded that Patients with multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock that underwent culprit lesion only percutaneous coronary intervention (PCI) had a lower 30-day risk of death or severe renal failure compared to those who had immediate multivessel PCI

In a study conducted at 83 European centers, the researchers randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke.

In the culprit-only arm, staged revascularization was performed in 17.7%. In the complete multivessel revascularization, complete revascularization was accomplished in 81.0% of patients. The crossover rate was 12.5% in the culprit-only group and 9.4% in the multivessel PCI arm.

For the primary endpoint, a 30-day composite of death or severe renal failure leading to renal-replacement therapy, the culprit-lesion-only approach was superior to the multivessel PCI approach (45.9% vs. 55.4%; relative risk, 0.83; p=0.01).

The relative risk of death was lower with more limited initial revascularization (RR, 0.84; p=0.03), and a trend towards less renal-replacement therapy was also seen (RR, 0.71; p=0.07).

No differences between approaches were seen in the amount of time to reach hemodynamic stability, the use of catecholamine therapy, the duration of ICU stay, or the use and duration of mechanical ventilation. There were also no differences between groups in levels of troponin T, creatine kinase, or rates of bleeding or stroke.

The investigators concluded that among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure was lower for those who initially underwent only PCI of the culprit lesion with the option of staged revascularization, compared to those who underwent immediate multivessel PCI. . Limitations of the trial included its lack of blinding and the relatively high crossover rate.