Conference Coverage
ACC/AHA guidelines upgrade multivessel PCI, downgrade thrombectomy
Guideline updates from two ACC/AHA writing committees upgraded multivessel PCI to include noninfarct arteries, and downgraded aspiration...
This study’s findings reinforce those of previous trials that had suggested that multivessel percutaneous coronary intervention has higher early mortality than culprit-lesion-only PCI.
The study provides compelling evidence that culprit-lesion-only PCI should be the preferred treatment choice over multivessel PCI in patients with cardiogenic shock.
A previous meta-analysis of patients with uncomplicated ST-segment elevation myocardial infarction showed lower rates of mortality or MI with initial multivessel PCI. The disagreement between the two studies suggests that patients with cardiogenic shock may experience greater risk of these adverse outcomes during multivessel PCI procedures.
Future clinical trials should test individual multivessel revascularization strategies to reduce mortality in MI patients with cardiogenic shock, such as coronary artery bypass grafting (CABG) and venoarterial extracorporeal membrane oxygenation (ECMO).
Judith Hochman, MD, and Stuart Katz, MD, of New York University Langone Health, made these comments in an accompanying editorial (N Engl J Med. 2017 Oct 30. doi: 10.1056/nejme1713341). Dr. Hochman had no relevant disclosures. Dr. Katz has consulted for Novartis, Amgen, and Regeneron, and has received funding from Amgen, American Regent, and Janssen.
FROM TCT 2017
In patients with acute myocardial infarction and multivessel coronary artery disease with cardiogenic shock, 30-day rates of death and renal-replacement therapy were lower when patients underwent percutaneous coronary intervention (PCI) of the culprit lesion as opposed to multivessel PCI.
The difference appeared to be driven by mortality, as the renal endpoint alone was not significant.
As many as 80% of patients with cardiogenic shock also present with multivessel coronary artery disease, and this is associated with worse mortality. It is unclear whether immediate PCI of clinically important stenoses of major nonculprit coronary arteries is of benefit, and previous randomized trials comparing the procedures did not look at patients with cardiogenic shock, Holger Thiele, MD, reported at the Transcatheter Cardiovascular Therapeutics annual educational meeting.
European guidelines suggest that PCI of nonculprit lesions should be considered in patients with cardiogenic shock, while U.S. guidelines offer no opinion, but recent appropriate use criteria recommend revascularization of a nonculprit artery if cardiogenic shock continues after the culprit artery has been repaired. It is thought that immediate revascularization of all coronary arteries with clinically important stenoses might improve overall myocardial perfusion and function in patients with cardiogenic shock, but the procedure could also have drawbacks, including additional ischemia, volume overload, and renal impairment from higher doses of contrast material.
To better understand outcomes in these patients, the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial randomized 706 patients to culprit-only PCI or multivessel PCI, in which PCI was performed on all major coronary arteries with more than 70% stenosis. Patients receiving culprit-only PCI could also undergo optional staged revascularization due to residual ischemic lesions, symptoms, or clinical or neurologic status.
At 30 days, death and/or renal-replacement therapy occurred in 45.9% of the culprit-only group, compared to 55.4% in the multivessel group (relative risk, 0.83; 95% confidence interval, 0.71-0.96; P = .01). A per-protocol analysis showed similar results (RR, 0.81; 95% CI, 0.69-0.96; P =.01), as did an analysis of the as-treated population (RR, 0.83; 95% CI, 0.72-0.97; P = .02).
All-cause mortality was lower in the culprit-only group (43.3% versus 51.6%; RR, 0.84; 95% CI, 0.72-0.98; P=.03). The rate of renal-replacement therapy was higher in the multivessel group (16.4% versus 11.6%), but this did not reach statistical significance (P = .07).
There were no statistically significant differences between the two groups with respect to recurrent myocardial infarction, rehospitalization for heart failure, bleeding, or stroke, Dr. Thiele reported at the meeting, which was sponsored by the Cardiovascular Research Foundation.
Some limitations of the study included its unblinded nature, and the fact that 75 patients originally assigned to one treatment category crossed over to the other, including 14 in the culprit-lesion only category who underwent immediate multivessel PCI. This suggests that treatment strategy may need to be adopted to a patient’s clinical circumstances.
The CULPRIT-SHOCK results were published online at the time of Dr. Thiele’s presentation (N Engl J Med. 2017 Oct 30. doi:10/056/NEJMoa1710261).
Several of the study’s authors reported financial ties to the pharmaceutical industry.
Guideline updates from two ACC/AHA writing committees upgraded multivessel PCI to include noninfarct arteries, and downgraded aspiration...