TCT 2017: Study challenges recommendations on the management of cardiogenic shock

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Holger Thiele

Advice on percutaneous coronary intervention (PCI) strategies for patients with acute myocardial infarction complicated by cardiogenic shock may need to be revised after the CULPRIT-SHOCK study showed that immediate multivessel PCI was associated with a significantly higher rate of all-cause death than was culprit-lesion only PCI in this patient cohort. The study also indicated that multivessel PCI was also associated with a trend towards more renal replacement therapy.

Presenting the results of CULPRIT-SHOCK at the 2017 Transcatheter Cardiovascular Therapeutics (TCT) meeting (29 October–2 November, Denver, USA), Holger Thiele (Heart Centre Leipzig-University Hospital, Leipzig, Germany) reported that current European guidelines for ST-segment elevation myocardial infarction (STEMI) say that immediate revascularisation of non-culprit lesions should be considered in patients with cardiogenic shock (IIa; level of evidence of C). He added that the while US guidelines did not have a “specific recommendation” for multivessel PCI in patients with cardiogenic shock, a recent US appropriate use criteria document did say that such a strategy was appropriate when cardiogenic shock persisted after revascularisation of the culprit artery.

However, according to Thiele, data for the use of multivessel PCI in patients with cardiogenic shock were limited. He noted that in a meta-analysis of 10 observational studies looking at cardiogenic shock, only 19.7% of patients had undergone multivessel PCI. Furthermore, this meta-analysis indicated lower mortality with culprit-only PCI—although, there was no difference in mortality at long-term follow-up.

Based on these data, Thiele and colleagues hypothesised that culprit-lesion only PCI (with possible staged revascularisation) would be superior to immediate multivessel PCI for patients with multivessel disease and with cardiogenic shock complicating acute myocardial infarction.  The aim of CULPRIT-SHOCK was to test this hypothesis.

Overall, 706 multivessel disease patients with acute myocardial infarction and cardiogenic shock were randomised to undergo culprit-lesion only PCI (351) or immediate multivessel PCI (355). Approximately, in each group, 50% of patients required resuscitation prior to randomisation, 60% had STEMI, and nearly 25% had at least one chronic total occlusion. The primary endpoint was the 30-day composite rate of all-cause death or renal replacement therapy.

At 30 days, the rate of the primary endpoint was significantly decreased in the culprit-lesion only group: 45.9% vs. 55.4% for immediate multivessel PCI (p=0.01). This result, said Thiele, was “mainly driven” by an absolute 8% reduction in all-cause death with culprit-lesion only PCI—43.3% vs. 51.6% for immediate multivessel PCI (p=0.03). Additionally, there was a non-significant trend towards a lower rate of renal replacement therapy in the culprit-lesion only PCI group (11.6 vs. 16.4%, respectively; p=0.07).

As well as being presented at TCT, CULPRIT-SHOCK was simultaneously published in The New England Journal of Medicine. In that journal, Thiele and colleagues comment that previous studies —in haemodynamically stable patients—have shown multivessel PCI to provide benefit over culprit-lesion only PCI. However, they note that these findings were “driven mainly by the difference in the rate of repeat revascularisation, which was counted as part of the composite endpoint”.

By contrast, staged revascularisation was encouraged and not counted as a disadvantage of culprit-lesion only PCI in CULPRIT-SHOCK. “Among patients with cardiogenic shock, the acute hazards of a prolonged procedure time (including the increased dose of contrast material) [with immediate multivessel PCI] seem to outweigh any potential negative aspects of repeat revascularisation,” the authors write.

Concluding his presentation at TCT, Thiele said: “This largest randomised European multicentre trial in cardiogenic shock complicating myocardial infarction challenges guideline recommendations.”

Speaking in the roundtable discussion after the presentation, Cindy Grines (Department of Cardiology, Detroit Medical Center Heart Hospital, Detroit, USA) said that the results were “not surprising” when the findings of the previous meta-analysis were considered. She added: “On the basis of CULPRIT-SHOCK, I would certainly adjust my strategy and just manage the culprit vessel”.

Thiele told Cardiovascular News that in patients with multivessel disease and cardiogenic shock, he would perform “staged revascularisation based on symptoms and/or ischaemia testing”.

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