CULPRIT-SHOCK Trial and ESC STEMI Guidelines

Ibanez B, Halvorsen S, Roffi M, et al.
Integrating the Results of the CULPRIT-SHOCK Trial in the 2017 ESC ST-Elevation Myocardial Infarction Guidelines: Viewpoint of the Task Force. Eur Heart J 2018;May 29:[Epub ahead of print].

The following are key points to remember from this European Society of Cardiology (ESC) task force viewpoint about integrating the results of the CULPRIT-SHOCK trial in the 2017 ESC ST-elevation myocardial infarction (STEMI) guideline:

  1. The recent 2017 ESC guidelines for the management of acute MI in patients presenting with STEMI favored complete revascularization during the index primary percutaneous coronary intervention (PCI), for the management of patients with cardiogenic shock complicating STEMI and with severe coronary stenosis apart from the infarct-related artery (IRA), allocating a Class of Recommendation IIa with Level of Evidence C.
  2. The evidence the guideline task force used to recommend non-IRA PCI during the index procedure in patients with STEMI and cardiogenic shock was based on indirect evidence and observational studies.
  3. After the publication of the STEMI guideline, the CULPRIT-SHOCK (Culprit Lesion Only PCI vs. Multivessel PCI in Cardiogenic Shock) trial demonstrated that routine complete revascularization during the index PCI procedure in this population is harmful.
  4. Based on the new robust evidence from the adequately powered CULPRIT-SHOCK trial, it is now the opinion of the 2017 STEMI task force that in patients with cardiogenic shock complicating STEMI, primary PCI should be restricted to the IRA.
  5. Immediate multivessel PCI may be justified in the rare cases where the IRA is difficult to identify or incorrectly defined initially, or when multiple culprit lesions are identified.
  6. Furthermore, selected cases in which there is a very severe flow-limiting non-IRA stenosis irrigating a large myocardial area may also justify immediate non-IRA PCI.
  7. Staged non-IRA PCI might be an option, carefully balancing the benefits and risks of a new procedure with additional contrast loading and risk of complications.
  8. At this time, decision making in STEMI patients with cardiogenic shock and multivessel disease should be based on available data from the CULPRIT-SHOCK trial, taking into consideration the individual patient using medical judgment based on the available evidence.
  9. It is important to note that data from nonrandomized, retrospective, and observational studies are potentially affected by important bias and might not represent a real effect. Data from randomized clinical trials represent the best evidence to guide therapies.
  10. The CULPRIT-SHOCK trial is the only randomized clinical trial performed addressing this issue and demonstrated that routine multivessel PCI during the index procedure in STEMI patients and cardiogenic shock is not safe.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease

Keywords: Acute Coronary Syndrome, Coronary Artery Disease, Constriction, Pathologic, Coronary Stenosis, Heart Failure, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk Assessment, Shock, Cardiogenic

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