Chronicles of Ellery Ivan MD

The Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) trial was designed to test the hypothesis that PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, would result in better clinical outcomes than immediate multivessel PCI among patients who have multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock.

Clinical Question: Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock would PCI of the culprit lesion only than among those who underwent immediate multivessel PCI result to better outcomes?

P: Patients were eligible for the trial if they had acute myocardial infarction with cardiogenic shock. Additional eligibility criteria were planned early revascularization by means of PCI, multivessel coronary artery disease (defined as at least two major vessels [≥2 mm in diameter] with >70% stenosis of the diameter), and an identifiable culprit lesion.

Criteria for cardiogenic shock included a systolic blood pressure of less than 90 mm Hg for longer than 30 minutes or the use of catecholamine therapy to maintain a systolic pressure of at least 90 mm Hg, clinical signs of pulmonary congestion, and signs of impaired organ perfusion with at least one of the following manifestations: altered mental status, cold and clammy skin and limbs, oliguria with a urine output of less than 30 ml per hour, or an arterial lactate level of more than 2.0 mmol per liter.

Exclusion criteria were resuscitation for longer than 30 minutes, no intrinsic heart action, an assumed severe deficit in cerebral function with fixed dilated pupils, an indication for primary urgent coronary-artery bypass grafting, single-vessel coronary artery disease, a mechanical cause of cardiogenic shock, the onset of shock more than 12 hours before randomization, an age of more than 90 years, shock with a noncardiogenic cause, massive pulmonary embolism, known severe renal insufficiency (creatinine clearance, <30 ml per minute), and other severe concomitant disease associated with a life expectancy of less than 6 months.

I: Either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. In all the patients, PCI of the culprit lesion was performed first, with the use of standard interventional techniques. In patients in the culprit-lesion-only PCI group, all other lesions were to be left untreated at the time of the initial procedure. In patients in the multivessel PCI group, PCI of all major coronary arteries with more than 70% stenosis of the diameter was to be performed. This included efforts to recanalize chronic total occlusions during the acute phase; the recommended maximum dose of contrast material was 300 ml.

O: PCI of the culprit lesion only (with the option of staged revascularization of nonculprit lesions) was superior to immediate multivessel PCI with respect to a composite end point of death or renal-replacement therapy at 30 days. The difference was driven mainly by significantly lower mortality in the culprit-lesion-only PCI group

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