March 1, 2023Journal of the American College of Cardiology
Influence of Culprit Lesion Intervention on Outcomes in Infarct-Related Cardiogenic Shock With Cardiac Arrest
Key result
Cardiac arrest in infarct-related cardiogenic shock predicts ~27% higher 1-year mortality, while culprit-only PCI remains superior.
- P=0.39
- n=1,015
Why the study?
Cardiac arrest is common in patients with infarct-related cardiogenic shock, but characteristics and outcomes of culprit lesion PCI stratified by cardiac arrest required evaluation.
Does culprit lesion-only PCI improve outcomes compared to immediate multivessel PCI in patients with infarct-related cardiogenic shock, regardless of the presence of cardiac arrest?
Key Points
- This study aims to evaluate the outcomes of culprit lesion PCI in patients with infarct-related cardiogenic shock, particularly those with cardiac arrest.
- Analyzed data from the CULPRIT-SHOCK study, involving 1,015 patients with cardiogenic shock.
- Assessed all-cause death and severe renal failure leading to renal replacement therapy at 30 days and 1 year.
- Stratified outcomes based on presence of cardiac arrest among patients.
- 51.2% of patients with cardiac arrest experienced all-cause death or severe renal failure within 30 days vs 48.5% in non-cardiac arrest patients (P=0.39).
- 1-year mortality was 53.8% in cardiac arrest patients compared to 50.4% in non-cardiac arrest patients (P=0.29).
- Culprit lesion-only PCI demonstrated superiority over multivessel PCI in all patients, regardless of the presence of cardiac arrest (P for interaction=0.6).
Study Design
Type
RCT (n=1,015)
Structured PICO
Does culprit lesion-only PCI improve outcomes compared to immediate multivessel PCI in patients with infarct-related cardiogenic shock, regardless of the presence of cardiac arrest?
P
Population
1,015 patients with infarct-related cardiogenic shock (CS) from the CULPRIT-SHOCK randomized trial and registry, including 550 (54.2%) with cardiac arrest (CA).
I
Intervention
Culprit lesion-only percutaneous coronary intervention (PCI)
C
Comparator
Immediate multivessel PCI
O
Outcome
Composite of all-cause death or severe renal failure leading to renal replacement therapy within 30 days, and 1-year deathcomposite
Main Result
Absolute Event Rate: 51.2% vs 48.5%
p-value: p=0.39
In patients with infarct-related cardiogenic shock, cardiac arrest is an independent predictor of 1-year mortality, but culprit lesion-only PCI remains the preferred revascularization strategy regardless of cardiac arrest status.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The consistent risk estimates for the primary endpoint in the intention-to-treat, per-protocol and as-treated analysis support the robustness of the findings. The CULPRIT-SHOCK trial provides compelling evidence that a strategy of culprit-lesion-only PCI is preferred over initial multivessel PCI for patients with cardiogenic shock.”
“I think this study gives us confirmation of our routine practice, in which we normally focus only on the culprit lesion because these patients have too many problems.”
HTHolger ThieleDirector, Heart Center Leipzig-University Hospital
“The interventional cardiologist treating a patient with cardiogenic shock after an acute myocardial infarction should do only the culprit lesion and later on do a staged revascularization.”
Implication
Culprit-only PCI remains preferred in cardiogenic shock regardless of cardiac arrest; extends CULPRIT-SHOCK evidence to this higher-risk subgroup but leaves confirmatory trials needed.
Abstract
BACKGROUND Cardiac arrest (CA) is common in patients with infarct-related cardiogenic shock (CS). OBJECTIVES The goal of this study was to identify the characteristics and outcomes of culprit lesion percutaneous coronary intervention (PCI) of patients with infarct-related CS stratified according to CA in the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) randomized trial and registry. METHODS Patients with CS with and without CA from the CULPRIT-SHOCK study were analyzed. All-cause death or severe renal failure leading to renal replacement therapy within 30 days and 1-year death were assessed. RESULTS Among 1,015 patients, 550 (54.2%) had CA. Patients with CA were younger, more frequently male, had lower rates of peripheral artery disease, a glomerular filtration rate <30 mL/min, and left main disease, and they presented more often with clinical signs of impaired organ perfusion. The composite of all-cause death or severe renal failure within 30 days occurred in 51.2% of patients with CA vs 48.5% in non-CA patients (P = 0.39) and 1-year death in 53.8% vs 50.4% (P = 0.29), respectively. In a multivariate analysis, CA was an independent predictor of 1-year mortality (HR: 1.27; 95% CI: 1.01-1.59). In the randomized trial, culprit lesion-only PCI was superior to immediate multivessel PCI in patients both with and without CA (P for interaction = 0.6). CONCLUSIONS More than 50% of patients with infarct-related CS had CA. These patients with CA were younger and had fewer comorbidities, but CA was an independent predictor of 1-year mortality. Culprit lesion-only PCI is the preferred strategy, both in patients with and without CA. (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock [CULPRIT-SHOCK]; NCT01927549).
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Cite This Study
Zeymer et al. (2023) conducted an RCT in Infarct-related cardiogenic shock (n=1,015). Cardiac arrest vs. No cardiac arrest was evaluated on Composite of all-cause death or severe renal failure leading to renal replacement therapy within 30 days (p=0.39). Cardiac arrest in infarct-related cardiogenic shock independently predicted 1-year mortality (HR 1.27; 95% CI 1.01-1.59), while culprit lesion-only PCI remained superior to multivessel PCI.