CULPRIT-SHOCK – 1-year Results Support Ongoing Updates to Guidelines on Multivessel Percutaneous Coronary Intervention in Patients with Cardiogenic Shock and Acute Myocardial Infarction
– Insight into the results of the CULPRIT-SHOCK trial, which were presented at the European Society of Cardiology Congress, Munich, Germany, 25–29 August 2018
Cardiogenic shock (CS) is the most common cause of death in patients with acute myocardial infarction (AMI). Although mortality rates remain high, previous studies have shown that these patients gain a survival benefit from early revascularisation.1
The majority of patients with CS present with multi-vessel disease (coronary stenoses/occlusions in more than one vessel), which is associated with worse mortality than single-vessel disease.1 There has been considerable debate around whether percutaneous coronary intervention (PCI) should be performed immediately for stenoses in non-culprit arteries in these patients.2
Current European Society of Cardiology (ESC) guidelines recommend immediate multi-vessel PCI in this patient population;3 American society guidelines do not offer a recommendation, but support exists for this approach in the criteria regarding the appropriate use of coronary revascularisation in patients with acute coronary syndromes.4
The 1-year results of the Culprit lesion only PCI versus multivessel PCI in cardiogenic shock (CULPRIT-SHOCK) trial presented at the ESC Congress 2018 sought to expand on the 30-day findings presented last year, which demonstrated that patients undergoing PCI for culprit vessels only – rather than multivessel PCI – had a lower risk of a composite of death or severe renal failure leading to renal replacement therapy.2
CULPRIT-SHOCK is an open-label, prospective, randomised, international multicentre trial that has been conducted across 83 centres. Overall, 706 patients with multivessel disease, AMI and CS were randomised to either multivessel PCI or PCI of the culprit lesion only, with the option of additional staged revascularisation of non-culprit lesions.
At 1 year, death had occurred in 172 of 344 patients (50.0%) in the culprit-vessel-only PCI group, compared with 194 of 341 patients (56.9%) in the multi-vessel PCI arm. The primary end point of composite death or renal replacement therapy had occurred in significantly fewer patients (45.9%) in the culprit-vessel-only PCI group compared with 55.4% in the multivessel PCI group at 30 days – this remained a relatively consistent difference over 1 year (52% versus 59.5%).5
Recurrent infarction rate was lower in patients in the culprit-only arm compared with multi-vessel PCI (1.7% versus 2.1%), as was the observation of composite of death or recurrent infarction (50.9% versus 58.4%).5
However, the study observed two outcomes that will require further discussion and consideration in routine practice. More patients required repeat revascularisation with culprit-vessel-only PCI than with multi-vessel PCI (32.3% versus 9.4%). Fourfold the number of patients in the culprit-vessel-only arm required rehospitalisation for heart failure, compared with the multi-vessel PCI group (5.2% versus 1.2%).5
Together with the 30-day results, the 1-year CULPRIT-SHOCK findings challenge the existing guidelines. Indeed, during this years’ conference, the ESC guidelines softened the evidence base in its recommendations on myocardial revascularisation.6 This reflects the implications of the CULPRIT-SHOCK observations and recognizes the ongoing debate on immediate multi-vessel PCI in patients with CS and AMI.
References
1. Thiele H, Ohman EM, Desch S, et al. Management of cardiogenic shock. Eur Heart J. 2015;36:1223–30.
2. Thiele H, Akin I, Sandri M, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med. 2017;377:2419–32.
3. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119–77.
4. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 appropriate use criteria for coronary revascularization in patients with acute coronary syndromes: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2017;69:570–91.
5. Thiele H, Akin I, Sandri M, et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med. 2018. doi: 10.1056/NEJMoa1808788
6. Neumann F, Sousa-Uva M, Ahlsson A, et al. ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2018. doi: 10.1093/eurheartj/ehy394