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Patients with acute myocardial infarction (AMI) presenting with cardiogenic shock have a poor prognosis. Current clinical guidelines recommend immediate cardiac catheterization with appropriate interventions. European investigators conducted a multicenter, randomized, controlled trial of either PCI of the culprit lesion only or multivessel PCI in 706 patients with multivessel disease, AMI, and cardiogenic shock.
PCI of chronic total occluded vessels was performed when possible in the multivessel PCI group. At 30 days, the rate of the primary endpoint, death or renal-replacement therapy, was significantly lower in the culprit-lesion-only PCI group than in the multivessel PCI group (46% vs. 55%; relative risk, 0.83%). Analyses performed in the per-protocol population compared with the as-treated population yielded only minor differences in relative risks. Analyses of prespecified subgroups (e.g., based on disease characteristics and comorbidities) revealed similar results in all subgroups. Mortality was significantly lower in the culprit-lesion-only PCI than in the multivessel PCI group (33% vs. 52%), whereas the groups did not differ significantly in the rates of renal-replacement therapy. Staged revascularization was performed in 18% of the culprit-lesion-only PCI group.
Thiele H et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med 2017 Oct 30; [e-pub]. (http://dx.doi.org/10.1056/NEJMoa1710261)
Hochman JS and Katz S.Back to the future in cardiogenic shock — Initial PCI of the culprit lesion only. N Engl J Med 2017 Oct 30; [e-pub]. (http://dx.doi.org/10.1056/NEJMe1713341)
Comment
Almost two decades have transpired since the original SHOCK trial, but 30-day mortality among patients with AMI presenting with cardiogenic shock has not changed dramatically. For patients with cardiogenic shock and multivessel disease, a strategy of culprit-only-lesion intervention provides the best outcome.
In a recent small study, complete revascularization was favored (NEJM JW Cardiol May 2015 and J Am Coll Cardiol 2015; 65:963), but in an older trial it was not (NEJM JW Cardiol Oct 2011 and J Am Coll Cardiol 2011; 58:704). None of these studies focused on patients with shock. The difference in the findings may be due to the increased length of the procedure for multivessel PCI, the myocardial depressive effects of the contrast material, the uselessness of opening a chronically occluded artery that may be supplying nonviable myocardium, or other unmeasured variables.
Methods for improving the prognosis of patients with cardiogenic shock continue to be an area requiring research.