PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock
Holger Thiele, Ibrahim Akin, Marcus Sandri, Georg Fuernau, Suzanne de Waha, Roza Meyer-Saraei, Peter Nordbeck, Tobias Geisler, Ulf Landmesser, Carsten Skurk, Andreas Fach, Harald Lapp, Jan J Piek, Marko Noc, Tomaž Goslar, Stephan B Felix, Lars S Maier, Janina Stepinska, Keith Oldroyd, Pranas Serpytis, Gilles Montalescot, Olivier Barthelemy, Kurt Huber, Stephan Windecker, Stefano Savonitto, Patrizia Torremante, Christiaan Vrints, Steffen Schneider, Steffen Desch, Uwe Zeymer, CULPRIT-SHOCK Investigators, Ulrich Tebbe, Jochen Wöhrle, Otmar Pachinger, Clemens Busch, Nathalie Pfeiffer, Alexander Neumer, Taoufik Ouarrak, Thomas Reimer, Christiane Lober, Peter Clemmensen, Ferenc Follath, Karl Wegscheider, M Zeitouni, P Overtchouk, P Guedeney, G Hage, Hauguel-Moreau, Ingo Eitel, Sabrina Weinschenk, Martin Borggrefe, Franz-Josef Neumann, Miroslaw Ferenc, Hans-Gerd Olbrich, Hans-Bernd Hopf, Adnan Kastrati, Antoinette de Waha, Heribert Schunkert, Gert Richardt, Bettina Schwarz, Mohamed Abdel-Wahab, Ralph Toelg, Volker Geist, Monika Bahnsen-Maaß, Marcus Hennersdorf, Jochen Graf, Urs Riemann, Dominik Scharpf, Klaus Empen, Mathias C Busch, Karl Werdan, Sebastian Nuding, Rainer Hambrecht, Eduard Fiehn, Anselm K Gitt, Bernd Mark, Ralph Winkler, Bernward Lauer, Sven Möbius-Winkler, Christian Schulze, Hans-Heinrich Minden, Rüdiger C Braun-Dullaeus, Alexander Schmeißer, Ruth H Strasser, Bernd Ebner, Georg Ertl, Harald Mudra, Martin Hug, Dierk Endemann, Christian Hamm, Claudia Walther, Christoph Liebetrau, Niels Menck, Julinda Mehilli, Martin Orban, Jörg Hausleiter, Steffen Massberg, Roland Prondzinsky, Stephan Gielen, Meinrad Gawaz, Matthias Pauschinger, Fadil Ademaj, Christoph Bode, Georg Nickenig, Stephan Fichtlscherer, Andreas Zeiher, Achim Viertel, Malte Kelm, Christian Jung, Carsten Sydow, Mahir Karakas, Volker Rudolph, Stephan Baldus, Claudius Jacobshagen, Gerd Hasenfuß, Dietrich Pfeiffer, Björn Buchter, Burkhard Hügl, Holger Nef, Oliver Dörr, Karsten Reinig, Karl Heinz Kuck, Alexander Ghanem, Hugo Katus, Tommaso Gori, Thomas Münzel, Steffen Schnupp, Johannes Brachmann, Markus Ferrari, Stephan Achenbach, Didier Carrié, Patrick Henry, Stephane Manzo-Silberman, Bertrand Ledermann, Guillaume Cayla, Jean-Louis Bonnet, Stefan Windecker, André Frenk, Raban Jeger, Eric Eeckhout, Jose P Henriques, Robert-Jan Van Geuns, Michiel Voskuil, M Bax, Pim van der Harst, Rokas Serpytis, Dalia Jarasuniene, Irene Marthe Lang, Philipp Pichler, Franz Weidinger, Marc-Michael Zaruba, Darius Dudek, Rafal Depukat, Adam Witkowski, Krzysztof Milewski, Janusz Prokopczuk, Mariusz Gąsior, Bogdan Gorycki, Andrzej Ochała, Luigi Piatti, Marcello Galvani, Irene Bossi, Reggio Emilia, Gianluca Pignatelli, John Greenwood, Tim Lockie, Mamas Mamas, Holger Thiele, Ibrahim Akin, Marcus Sandri, Georg Fuernau, Suzanne de Waha, Roza Meyer-Saraei, Peter Nordbeck, Tobias Geisler, Ulf Landmesser, Carsten Skurk, Andreas Fach, Harald Lapp, Jan J Piek, Marko Noc, Tomaž Goslar, Stephan B Felix, Lars S Maier, Janina Stepinska, Keith Oldroyd, Pranas Serpytis, Gilles Montalescot, Olivier Barthelemy, Kurt Huber, Stephan Windecker, Stefano Savonitto, Patrizia Torremante, Christiaan Vrints, Steffen Schneider, Steffen Desch, Uwe Zeymer, CULPRIT-SHOCK Investigators, Ulrich Tebbe, Jochen Wöhrle, Otmar Pachinger, Clemens Busch, Nathalie Pfeiffer, Alexander Neumer, Taoufik Ouarrak, Thomas Reimer, Christiane Lober, Peter Clemmensen, Ferenc Follath, Karl Wegscheider, M Zeitouni, P Overtchouk, P Guedeney, G Hage, Hauguel-Moreau, Ingo Eitel, Sabrina Weinschenk, Martin Borggrefe, Franz-Josef Neumann, Miroslaw Ferenc, Hans-Gerd Olbrich, Hans-Bernd Hopf, Adnan Kastrati, Antoinette de Waha, Heribert Schunkert, Gert Richardt, Bettina Schwarz, Mohamed Abdel-Wahab, Ralph Toelg, Volker Geist, Monika Bahnsen-Maaß, Marcus Hennersdorf, Jochen Graf, Urs Riemann, Dominik Scharpf, Klaus Empen, Mathias C Busch, Karl Werdan, Sebastian Nuding, Rainer Hambrecht, Eduard Fiehn, Anselm K Gitt, Bernd Mark, Ralph Winkler, Bernward Lauer, Sven Möbius-Winkler, Christian Schulze, Hans-Heinrich Minden, Rüdiger C Braun-Dullaeus, Alexander Schmeißer, Ruth H Strasser, Bernd Ebner, Georg Ertl, Harald Mudra, Martin Hug, Dierk Endemann, Christian Hamm, Claudia Walther, Christoph Liebetrau, Niels Menck, Julinda Mehilli, Martin Orban, Jörg Hausleiter, Steffen Massberg, Roland Prondzinsky, Stephan Gielen, Meinrad Gawaz, Matthias Pauschinger, Fadil Ademaj, Christoph Bode, Georg Nickenig, Stephan Fichtlscherer, Andreas Zeiher, Achim Viertel, Malte Kelm, Christian Jung, Carsten Sydow, Mahir Karakas, Volker Rudolph, Stephan Baldus, Claudius Jacobshagen, Gerd Hasenfuß, Dietrich Pfeiffer, Björn Buchter, Burkhard Hügl, Holger Nef, Oliver Dörr, Karsten Reinig, Karl Heinz Kuck, Alexander Ghanem, Hugo Katus, Tommaso Gori, Thomas Münzel, Steffen Schnupp, Johannes Brachmann, Markus Ferrari, Stephan Achenbach, Didier Carrié, Patrick Henry, Stephane Manzo-Silberman, Bertrand Ledermann, Guillaume Cayla, Jean-Louis Bonnet, Stefan Windecker, André Frenk, Raban Jeger, Eric Eeckhout, Jose P Henriques, Robert-Jan Van Geuns, Michiel Voskuil, M Bax, Pim van der Harst, Rokas Serpytis, Dalia Jarasuniene, Irene Marthe Lang, Philipp Pichler, Franz Weidinger, Marc-Michael Zaruba, Darius Dudek, Rafal Depukat, Adam Witkowski, Krzysztof Milewski, Janusz Prokopczuk, Mariusz Gąsior, Bogdan Gorycki, Andrzej Ochała, Luigi Piatti, Marcello Galvani, Irene Bossi, Reggio Emilia, Gianluca Pignatelli, John Greenwood, Tim Lockie, Mamas Mamas
Abstract
Background: In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial.
Methods: In this multicenter trial, we randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke.
Results: At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P=0.01). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P=0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P=0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ significantly between the two groups.
Conclusions: Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI. (Funded by the European Union 7th Framework Program and others; CULPRIT-SHOCK ClinicalTrials.gov number, NCT01927549 .).
Source: PubMed