乌鸦传媒

MUNICH -- With longer follow-up, multivessel stenting showed a trend toward inferior survival for patients with acute MI complicated by cardiogenic shock, according to the latest CULPRIT-SHOCK results.

At 1-year, death rates were comparable among the 706 patients with multivessel disease who were randomized to percutaneous coronary intervention (PCI) of the culprit lesion alone or multiple vessels (50.0% vs 56.9%, RR 0.88, 95% CI 0.76-1.01), reported investigators led by Holger Thiele, MD, of Heart Center Leipzig at University of Leipzig in Germany.

There were also no significant differences between the groups for rates of recurrent MI, at 1.7% with culprit-lesion only vs 2.1% with multiple vessel (RR 0.85, 95% CI 0.29-2.50) and combined death or recurrent infarction (50.9% vs 58.4%, respectively, RR 0.87, 95% CI 0.76-1.00), Thiele said at a late-breaking trial session at the European Society of Cardiology (ESC) meeting here.

The updated data were published simultaneously online in the .

"The results of the landmark analysis showed a benefit of culprit-lesion-only PCI over multivessel PCI with respect to short-term mortality, and there was no statistical difference between the two groups in mortality thereafter. These findings do not support the hypothesis that immediate multivessel PCI is associated with a higher short-term risk of death than culprit-lesion-only PCI but with a diminished risk during the longer-term course," the investigators noted.

Because of this trial, the recommend culprit-lesion-only PCI as the default strategy in acute MI patients with cardiogenic shock.

Holger Thiele, MD, presenting the results at ESC

CULPRIT-SHOCK previously showed that death or renal-replacement therapy was substantially less common in the first 30 days when patients only got the culprit lesion stented (45.9% versus 55.4% for multivessel PCI, P=0.01).

Mortality rates at 1 year were close enough that the early survival benefit of culprit-only revascularization appeared to be sustained at 1 year without significant attenuation, commented David Cohen, MD, of Saint Luke's Mid America Heart Institute in Kansas City, Missouri, who was not involved in the trial.

"Overall, I find these results to be reassuring that less is still more in the management of patients with acute MI and cardiogenic shock," he told 乌鸦传媒.

What did appear to be advantageous for multivessel stenting in this setting were the 1-year risks of repeat revascularization (9.4% vs 32.3% with culprit-lesion only, RR 3.44, 95% CI 2.39-4.95) and rehospitalization for heart failure (1.2% versus 5.2%, respectively, RR 4.46, 95% CI 1.53-13.04).

Thiele's group speculated that a higher rate of complete revascularization in the multivessel PCI group led to better ventricular function and a lower subsequent incidence of heart failure. Additionally, they suggested, perhaps more culprit-lesion-only PCI recipients simply survived long enough to develop heart failure.

"Although there was a clear excess of rehospitalization for heart failure in the culprit-only group, the overall rates were quite low and the absolute risk difference was fairly small," Cohen said. "In my opinion, this 'benefit' of complete revascularization does not offset the early and sustained higher mortality rate with this strategy."

Serial echocardiography was not performed and would have been useful in understanding the reasons for the differences in mortality and rehospitalization for heart failure, Thiele and colleagues acknowledged.

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