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Study Summary

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In the CULPRIT-SHOCK trial, patients with acute myocardial infarction, cardiogenic shock and multivessel coronary artery disease randomized to a strategy of immediate culprit-lesion-only percutaneous coronary intervention (PCI) experienced lower rates of death and severe renal failure leading to renal replacement therapy at 30 days in comparison with those assigned to a strategy of immediate multivessel PCI (see accompanying Hurst’s Central Illustration). These short-term results challenged previous European guidelines endorsing immediate PCI of both culprit and nonculprit lesions, resulting in a downgrade to a Class IIIB recommendation. However, questions remained as to whether effects of a strategy of immediate multivessel PCI might differ with longer-term follow-up. In this study, 1-year follow-up was available for 706 patients randomly assigned to culprit-lesion only PCI (n=344) or immediate multivessel PCI (n=341). In the former group, staged revascularization was performed in 18% of patients based on symptoms or evidence of ischemia. In the latter group, all lesions >70% were revascularized, including chronic total occlusions (CTOs). At 1 year, there was no significant difference in mortality between the two PCI strategies, although there was a statistically significant increase in repeat revascularizations as well as hospitalizations for heart failure with the culprit-lesion-only PCI strategy.

Commentary

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Study Strengths: This study provides the important addition of long-term follow-up to CULPRIT-SHOCK, a well-designed and conducted randomized controlled trial of revascularization strategies in cardiogenic shock complicating acute myocardial infarction. The 1-year follow-up provides novel, helpful data informing the natural history of coronary artery disease after initial revascularization for cardiogenic shock, including incidence of repeat revascularization and rehospitalization for heart failure. Absence of a late benefit of immediate multivessel PCI for mortality serves to confirm conclusions drawn from the initial analysis favoring a strategy of culprit-lesion only PCI and will likely inform future guideline statements.

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Study Limitations: Findings at 1-year follow-up must be considered exploratory as CULPRIT-SHOCK was designed to test 30-day outcomes. The mandatory inclusion of CTO PCI in the immediate multivessel PCI treatment arm is a notable choice that may differ from clinical practice, given a paucity of data for this strategy, and raises the question of whether a multivessel PCI strategy omitting CTO PCI would fare differently in comparison with culprit-lesion only PCI.

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Next Steps: Further research is necessary to elucidate the association between excess mortality and immediate multivessel PCI and the association between rehospitalization for heart failure with culprit-lesion-only PCI. For patients treated with a culprit-lesion only strategy, more data are needed to inform optimal management and timing of staged revascularization for residual ‘non-culprit’ disease and to understand the implications of this revascularization for rehospitalization for heart failure.

Trial Reference

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Thiele  H, Akin  I, Sandri  M, et al. One-year outcomes after PCI strategies in cardiogenic shock. N. Engl. J. Med. doi: 10.1056/NEJMoa1808788

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