1-year outcomes still support culprit-only PCI for cardiogenic shock
For patients with acute myocardial infarction (MI) complicated by cardiogenic shock, stenting only the culprit lesion showed a trend toward improved one-year survival when compared to multivessel PCI, according to the latest results of the CULPRIT-SHOCK trial presented at the European Society of Cardiology Congress in Munich.
Among 706 patients with multivessel disease randomized to either strategy, the single-vessel approach yielded a 50 percent mortality rate at one year while multivessel PCI was associated with 56.9 percent mortality. The difference wasn’t statistically significant, and neither were the rates of recurrent MI (1.7 percent for culprit-lesion only versus 2.1 percent for multivessel) or the combination of recurrent MI and death (50.9 percent versus 58.4 percent, respectively).
“The results of the landmark analysis showed a benefit of culprit-lesion-only PCI over multivessel PCI with respect to short-term mortality, and there was no statistical difference between the two groups in mortality thereafter,” reported lead author Holger Thiele, MD, of Heart Center Leipzig in Leipzing, Germany, and colleagues. The results were published in the New England Journal of Medicine simultaneously with the presentation at the ESC Congress.
“These findings do not support the hypothesis that immediate multivessel PCI is associated with a higher short-term risk of death than culprit-lesion-only PCI but with a diminished risk during the longer-term course.”
Thiele presented the 30-day results of CULPRIT-SHOCK at the 2017 Transcatheter Cardiovascular Therapeutics (TCT) scientific sessions. At that point, all-cause mortality was 43.3 percent among patients receiving culprit-lesion only PCI and 51.5 percent for those undergoing multivessel PCI. Based on the results of that trial, European guidelines downgraded multivessel PCI in the setting of cardiogenic shock.
Thiele et al. called their one-year results “exploratory” because the trial was initially powered for a 30-day analysis. Nevertheless, they noted two secondary endpoints were higher with culprit-only PCI: repeat revascularization (32.3 percent versus 9.4 percent) and rehospitalization for heart failure (5.2 percent versus 1.2 percent).
“Patients with cardiogenic shock are at an extreme risk for death, and if they die early, they therefore do not survive long enough for heart failure to develop in the longer-term course,” Thiele and colleagues explained. “Accordingly, because culprit-lesion-only PCI has shown a benefit over multivessel PCI with respect to short-term survival, the risk of heart failure within the first year may be higher with culprit-lesion-only PCI than with multivessel PCI.”
The authors said another explanation for the difference in hospitalizations for heart failure could be due to more complete revascularization—and subsequent improved ventricular function—in the multivessel PCI group.
Thiele et al. also pointed out the increase in repeat revascularization with single-vessel PCI didn’t appear to be associated with “hard” outcomes over the long term.
“Among patients who have cardiogenic shock, the short-term risks that are associated with longer procedure times, more complex initial interventions, and higher doses of contrast material seem to outweigh any potential benefits associated with reducing the subsequent risk of repeat revascularization,” the authors wrote.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.