Holger Thiele1, Ibrahim Akin1, Marcus Sandri1, Georg Fuernau1, Suzanne de Waha1, Roza Meyer-Saraei1, Peter Nordbeck1, Tobias Geisler1, Ulf Landmesser1, Carsten Skurk1, Andreas Fach1, Harald Lapp1, Jan J Piek1, Marko Noc1, Tomaž Goslar1, Stephan B Felix1, Lars S Maier1, Janina Stepinska1, Keith Oldroyd1, Pranas Serpytis1, Gilles Montalescot1, Olivier Barthelemy1, Kurt Huber1, Stephan Windecker1, Stefano Savonitto1, Patrizia Torremante1, Christiaan Vrints1, Steffen Schneider1, Steffen Desch1, Uwe Zeymer1. 1. From Heart Center Leipzig, University Hospital, Leipzig (H.T., M.S., S.D.), Universitätsmedizin Mannheim, Mannheim (I.A.), University Heart Center Lübeck, Lübeck (G.F., S. de Waha, R.M.-S.), German Center for Cardiovascular Research (DZHK) (G.F., S. de Waha, R.M.-S., U.L., C.S., S.B.F., S.D.) and Universitätsklinikum Charité, Campus Benjamin Franklin (U.L., C.S.), Berlin, Universitätsklinikum Würzburg, Würzburg (P.N.), Klinikum der Eberhard-Karls-Universität Tübingen, Tübingen (T. Geisler), Klinikum Links der Weser, Bremen (A.F.), Helios Klinik Erfurt, Erfurt (H.L.), Ernst-Moritz-Arndt-Universität, Greifswald (S.B.F.), Universitäres Herzzentrum Regensburg, Regensburg (L.S.M.), and Institut für Herzinfarktforschung (S. Schneider, U.Z.) and Klinikum Ludwigshafen (U.Z.), Ludwigshafen - all in Germany; Academic Medical Center, Amsterdam (J.J.P.); University Medical Center Ljubljana, Ljubljana, Slovenia (M.N., T. Goslar); Institute of Cardiology, Warsaw, Poland (J.S.); Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Vilnius University Hospital Santaros Klinikos and Faculty of Medicine, Vilnius University, Vilnius, Lithuania (P.S.); Sorbonne Université Paris 6, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière (G.M., O.B.), and Applied Research, Technology Transfer, Industrial Collaboration, Société Par Actions Simplifiée (P.T.), Paris; Wilhelminenspital, Department of Cardiology, and Sigmund Freud University, Medical School, Vienna (K.H.); University of Bern, Inselspital, Bern, Switzerland (S. Windecker); Manzoni Hospital, Lecco, Italy (S. Savonitto); and Universitair Ziekenhuis Antwerp, Antwerp, Belgium (C.V.).
Abstract
BACKGROUND: In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means ofpercutaneous 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 .).
RCT Entities:
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 .).
Authors: Manal Alasnag; Alexander G Truesdell; Holli Williams; Sara C Martinez; Syeda Kashfi Qadri; John P Skendelas; William A Jakobleff; Mirvat Alasnag Journal: Curr Atheroscler Rep Date: 2020-04-23 Impact factor: 5.113
Authors: Behnam N Tehrani; Alexander G Truesdell; Mitchell A Psotka; Carolyn Rosner; Ramesh Singh; Shashank S Sinha; Abdulla A Damluji; Wayne B Batchelor Journal: JACC Heart Fail Date: 2020-11 Impact factor: 12.035