Culprit lesion-only PCI bests multivessel PCI in reducing deaths, renal failure
Performing percutaneous coronary intervention (PCI) on culprit lesion only, rather than a multivessel PCI, reduces the 30-day composite risk of death or severe renal failure in patients with acute myocardial infarction (MI) complicated by cardiogenic shock and multivessel disease, according to the CULPRIT-SHOCK* study presented at the TCT 2017 Congress held in Denver, Colorado, US.
“Although PCI of the culprit lesion is the established standard of care, the management of nonculprit lesions is the subject of intense debate,” said the investigators. “Complete revascularization has been thought to be beneficial in improving ventricular function and haemodynamic status … However, immediate multivessel PCI might pose additional risks.”
At 30 days, the risk of a composite of all-cause mortality or severe renal failure was 17 percent lower in the culprit-lesion-only than the multivessel PCI groups (rate, 45.9 percent vs 55.4 percent, relative risk [RR], 0.83; p=0.01). The findings were consistent across prespecified subgroups, including those based on the presence of a chronic total occlusion. [N Engl J Med 2017;doi:10.1056/NEJMoa1710261]
“The difference was driven mainly by significantly lower mortality in the culprit-lesion-only PCI group,” observed the researchers, noting that deaths from any cause occurred in 43.3 percent of the culprit-lesion-only PCI group vs 51.5 percent of the multivessel PCI group (RR, 0.84; p=0.03), while the difference in renal replacement therapy rates was not statistically significant (11.6 percent vs 16.4 percent, RR 0.71; p=0.07).
No significant differences were observed in the rates of bleeding and stroke, time to haemodynamic stabilization, or the requirement for catecholamine therapy and its duration between the two groups.
“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,” wrote Drs Judith Hochman and Stuart Katz of New York University Langone Health in New York, New York, US, in an accompanying editorial. [N Engl J Med 2017;doi:10.1056/NEJMe1713341]
The results of the trial are in contrast with those involving MI patients with stable haemodynamics or uncomplicated STEMI**, which show that the rate of major adverse cardiac events is lower with multivessel PCI than with culprit lesion-only PCI. [J Am Coll Cardiol 2015;65:963-972; Lancet 2015;386:665-671; Can J Cardiol 2016;32:1542-1551] To this, Hochman and Katz commented that “these disparate findings suggest that patients with cardiogenic shock may be at an increased risk for adverse outcomes during complex multivessel PCI procedures.”
“Cardiogenic shock during MI is a relatively rare, but extremely dangerous condition, in which the heart is unable to pump enough blood to meet the body's needs,” said lead author Dr Holger Thiele, director of the Heart Center Leipzig at University Hospital in Leipzig, Germany.
Unlike other trials, this trial did not exclude patients with chronic total occlusion to allow for better representation of real-world patients with cardiogenic shock and multivessel disease, according to Thiele and co-authors, who said their exclusion would lead to “a major selection bias and a lower-risk cohort.”
The multicentre open-label trial involved 706 patients with acute STEMI or NSTEMI*** complicated by cardiogenic shock and presenting with multivessel disease and an identifiable culprit lesion. They were randomized to initial revascularizaton strategy by means of either culprit lesion-only PCI (with staged further PCI of nonculprit lesions an option), or immediate multivessel PCI.
“Additional trials are warranted to test strategies that may further reduce mortality,” suggested Hochman and Katz, alluding to CABG# and ECMO##.