Does routine complete revascularization during index primary PCI improve outcomes compared to culprit lesion only PCI in patients with cardiogenic shock complicating STEMI and multivessel disease?
This viewpoint highlights that the CULPRIT-SHOCK trial results challenge the 2017 ESC STEMI guidelines, which previously favored complete revascularization in STEMI patients with cardiogenic shock.
The recent 2017 European Society of Cardiology (ESC) Guidelines for the management of acute myocardial infarction in patients presenting with ST-elevation myocardial infarction (STEMI GL). 1 included 159 recommendations based on 477 references. Although the field of acute myocardial infarction is highly evidence-based many treatment options have never been tested in prospective randomized clinical trials (RCTs). Under these circumstances the guideline task force (TF) is expected to develop clinically useful recommendations using consensus based on available evidence from small trials or observational studies or plain clinical experience level of evidence (LOE) C. In the recent STEMI guidelines, 49% of the recommendations were labelled as LOE C. Many of these LOE C recommendations were acknowledged as relevant areas for future research in the 2017 STEMI GL document. egarding the management of patients with cardiogenic shock complicating STEMI and with severe coronary stenosis apart from the infarct-related artery (IRA), the recent 2017 STEMI GL 1 favoured complete revascularization during the index primary percutaneous coronary intervention (PCI), allocating a class of recommendation IIa with LOE C. After the publication of the STEMI GL, 1 the 'Culprit Lesion Only PCI vs. Multivessel PCI in Cardiogenic Shock' (CULPRIT-SHOCK) trial demonstrated that routine complete revascularization during index PCI procedure in this population is harmful. A selected group of members of the 2017 STEMI GL TF leading the chapters related to this topic decided to write this document. To get the broadest view of this relevant topic, additional authors were invited to participate in this document, including the principal investigator of CULPRIT-SHOCK (H.T.), the chair of the ESC Committee for Practice Guidelines (CPG) (S.W.), and the chair of the upcoming 2018 ESC Myocardial Revascularization GL (F.-J.N.).
Ibáñez et al. (Fri,) studied this question.
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