CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock)
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 13 Linguagem: Inglês
10.1161/circulationaha.117.032907
ISSN1524-4539
Autores Tópico(s)Cardiac Arrest and Resuscitation
ResumoHomeCirculationVol. 137, No. 13CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock) Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBCULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock)Implications on Guideline Recommendations Holger Thiele, MD and Steffen Desch, MD Holger ThieleHolger Thiele Heart Center Leipzig–University Hospital, Germany (H.T., S.D.) and Steffen DeschSteffen Desch Heart Center Leipzig–University Hospital, Germany (H.T., S.D.) German Center for Cardiovascular Research, Lübeck, Germany (S.D.) Originally published27 Mar 2018https://doi.org/10.1161/CIRCULATIONAHA.117.032907Circulation. 2018;137:1314–1316Mortality of cardiogenic shock complicating myocardial infarction can be reduced by an early invasive strategy with percutaneous coronary intervention (PCI) of the infarct-related artery. Up to 80% of patients with cardiogenic shock present with multivessel coronary artery disease, and their mortality is higher compared with patients with single-vessel disease.Until recently, there were no randomized data on how to deal with nonculprit lesions in the setting of cardiogenic shock. This lack of evidence is also reflected by divergent recommendations in current international guidelines. The European ST-segment–elevation acute myocardial infarction (STEMI) guidelines, published in 2017, recommend immediate PCI of nonculprit lesions in patients with cardiogenic shock (Class IIb, Level of Evidence C),1 whereas the American STEMI guidelines give no specific recommendation.2 However, American appropriate use criteria, also published in 2017, consider immediate revascularization of a nonculprit artery during the same procedure appropriate if cardiogenic shock persists after treatment of the culprit artery.3After publication of the randomized, multicenter CULPRIT-SHOCK trial (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), guidelines and appropriate use criteria need to be reconsidered. To briefly recap, CULPRIT-SHOCK showed a significant clinical benefit of a culprit-lesion-only strategy with a reduction in the primary end point of 30-day mortality or severe renal failure requiring renal replacement therapy (45.9% culprit-lesion-only PCI versus 55.4% immediate multivessel PCI group; relative risk, 0.83; 95% confidence interval, 0.71–0.96; P=0.01), which was driven mainly by an absolute 8.2% reduction in 30-day mortality (43.3% versus 51.5%; relative risk, 0.84; 95% confidence interval, 0.72–0.98; P=0.03).4What Is the EFFECT of CULPRIT-SHOCK on Guidelines?With the application of current guideline criteria, the results of CULPRIT-SHOCK may lead to a Class I, Level of Evidence B (moderate-quality evidence from ≥1 randomized controlled trials) or Level of Evidence A (≥1 randomized controlled trials corroborated by high-quality registry studies) recommendation to limit PCI to the culprit lesion on a routine basis with possible staged revascularization. Likewise, it would also be possible to give a Class III, Level of Evidence B recommendation to perform routine immediate multivessel PCI in this setting.Are There Specific Situations in Which Immediate Multivessel PCI Is Still Appropriate?The results of CULPRIT-SHOCK were consistent across all predefined subgroups. This included sex, all age groups, presence/absence of diabetes mellitus, presence/absence of hypertension, STEMI or non-STEMI, anterior/nonanterior STEMI, previous/no previous infarction, double-/triple-vessel disease, or presence/absence of chronic total occlusion (CTO). Intuitively, some angiographic subgroups, such as occluded right coronary artery culprit lesion with a concomitant high-grade proximal left anterior descending coronary artery or additional nonculprit subtotal lesions with TIMI (Thrombolysis in Myocardial Infarction) grade 1 or 2 flow, may call for immediate multivessel PCI. However, this is not supported by the predefined subgroup analysis in which culprit-lesion-only PCI in nonanterior infarctions had a hazard ratio of 0.67 (95% confidence interval, 0.48–0.94). Additional analyses based on findings of the central angiographic core laboratory will be performed to identify angiographic predictors of outcome.There were some crossovers in the culprit-lesion-only PCI group to immediate multivessel PCI based mainly on the individual decision of the interventionalist for multiple reasons such as lack of hemodynamic improvement and plaque shifts. This suggests that the treatment strategy may require adaptation in certain circumstances. However, cardiogenic shock after PCI of the culprit lesion persists in the catheterization laboratory in nearly all patients and should not be used as a decision to perform immediate multivessel PCI.Was There Any Influence of the Presence of CTO on Outcome?It is well known that the presence of a CTO is frequent in cardiogenic shock and associated with high mortality.5 Therefore, CTO presence was not defined as an exclusion criterion in CULPRIT-SHOCK, which is different from all other STEMI trials without cardiogenic shock. This allowed the inclusion of a real-world cohort of patients. Exclusion of CTO would have led to a major selection bias and a lower-risk cohort. It was therefore also recommended to intervene on the CTO. However, technically, CTO intervention needed to be deemed easily possible, with a limit of contrast agent of 300 cm3 for the overall immediate multivessel PCI procedure. No retrograde or other complex interventional approaches were recommended. At least 1 CTO was present in 22.4% in the culprit-lesion-only arm and in 24.0% in the immediate multivessel PCI arm. In CULPRIT-SHOCK, immediate CTO recanalization was attempted in roughly 50% of patients in the immediate multivessel PCI group and was successful in approximately one third of attempts. The results for the primary study end point were consistent for CTO presence or absence, as shown in the predefined subgroup analysis (P for interaction=0.26). Thus, neither the presence of CTO nor a CTO intervention influenced the overall outcome for both treatment strategies.EFFECT of Staged Revascularization and Timing of Staged RevascularizationIn contrast with many of the trials in STEMI without cardiogenic shock, in CULPRIT-SHOCK, staged revascularization was encouraged and was not counted as a disadvantage for the culprit-lesion-only PCI strategy. In past studies of stable patients with STEMI, the differences between culprit-lesion-only PCI and immediate multivessel PCI or early staged PCI were driven mainly by the difference in the rate of repeat revascularization, counted as part of a composite end point. In CULPRIT-SHOCK, 21.5% of patients underwent staged or urgent repeat revascularization within the 30-day follow-up. This rate appears to be higher compared with stable STEMI revascularization strategy trials (COMPARE-ACUTE [Comparison Between FFR Guided Revascularization Versus Conventional Strategy in Acute STEMI Patients With MVD], 17.4% at the 1-year follow-up; CvLPRIT [Complete Versus Lesion-Only Primary PCI Trial], 8.2% at the 1-year follow-up; DANAMI-3-PRIMULTI [Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization], 17% at the 1-year follow-up; PRAMI [Preventive Angioplasty in Acute Myocardial Infarction], 16% at the 6-month follow-up) and might be related to the extent of coronary artery disease, the impaired left ventricular function, and the nature of disease in cardiogenic shock.At present, the optimal timing of staged revascularization has not been adequately investigated, and no recommendation can be formulated in favor of a staged multivessel PCI during the index hospitalization, after discharge, or at longer follow-up only in case of symptoms or signs of ischemia. In general, patients with cardiogenic shock require much longer hospitalization and often neurological rehabilitation because of previous resuscitation (>50% of patients in CULPRIT-SHOCK). Thus, timing and the requirement for staged revascularization may differ in patients with cardiogenic shock compared with patients without shock.What Are the Reasons for the Difference in Outcome?The higher 30-day mortality in the immediate multivessel PCI arm in CULPRIT-SHOCK might be related to the significantly higher dose of contrast medium (190 cm3 versus 250 cm3; P<0.001) and a subsequent decline in renal function. There was a lower estimated glomerular filtration rate in the immediate multivessel PCI group compared with the culprit-lesion-only PCI group at days 3 and 4. However, the incidence of severe renal failure leading to renal replacement therapy did not differ significantly (11.6% versus 16.4%; P=0.07). The higher dose of contrast medium in the immediate multivessel PCI group also may have led to acute left ventricular volume overload with a negative effect on myocardial function and recovery. In addition, the prolonged duration of the multivessel PCI procedure may be hazardous at a time when the patient is hemodynamically compromised, leading to potentially more bleeding and inflammation. Additional myocardial damage may have been induced by PCI in stable lesions. Further subanalyses using biomarkers from the central core laboratory of renal function, inflammation, and myocardial damage, as well as detailed angiographic analyses, will be performed to elucidate the potential underlying mechanisms for the difference in mortality.ConclusionsFrom our perspective, CULPRIT-SHOCK clearly challenges current guidelines and appropriate use criteria. Culprit-lesion-only PCI with possible staged revascularization should be the preferred revascularization strategy, which can also be translated as "keep the revascularization strategy simple." Immediate routine multivessel PCI should be avoided in patients with multivessel coronary artery disease and cardiogenic shock complicating acute myocardial infarction.Sources of FundingFunding was provided by the European Union, Seventh Framework Program (FP7/2007–2013), grant agreement 602202, German Heart Research Foundation, and German Cardiac Society.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.http://circ.ahajournals.orgHolger Thiele, MD, Director, Heart Center Leipzig–University Hospital, Department of Internal Medicine/Cardiology, Strümpellstrasse 39, 04289 Leipzig, Germany. E-mail [email protected]References1. 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March 27, 2018Vol 137, Issue 13 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.032907PMID: 29581361 Originally publishedMarch 27, 2018 Keywordsmyocardial revascularizationpercutaneous coronary interventionangioplastymyocardial infarctionshock, cardiogenicPDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsPercutaneous Coronary InterventionRevascularizationStent
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