Association of Culprit Lesion Location With Outcomes of Culprit-Lesion-Only vs Immediate Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock

Abstract

with a culprit lesion located in the left main or proximal left anterior descending artery compared with other coronary segments is associated with more myocardium at risk and worse clinical outcomes.OBJECTIVE To evaluate the association of culprit lesion location with outcomes of culprit-lesion-only percutaneous coronary intervention with optional staged revascularization vs immediate multivessel percutaneous coronary intervention in patients with multivessel disease, myocardial infarction, and cardiogenic shock. DESIGN, SETTING, AND PARTICIPANTS Post hoc analysis of the Culprit Lesion Only Coronary Intervention vs Multivessel Coronary Intervention in Cardiogenic Shock (CULPRIT-SHOCK), an investigator-initiated randomized, open-label clinical trial. Patients with multivessel disease, acute myocardial infarction, and cardiogenic shock were enrolled at 83 European centers from April 2013 through April 2017.INTERVENTIONS Patients were randomized to culprit-lesion-only percutaneous coronary intervention with optional staged revascularization or immediate multivessel percutaneous coronary intervention (1:1). For this analysis, patients were stratified by culprit lesion location in the left main or proximal left anterior descending artery group and other-culprit-lesion location group. MAIN OUTCOMES AND MEASURESEnd points included a composite of death or kidney replacement therapy at 30 days and death at 1 year. RESULTSThe median age of the study population was 70 (interquartile range, 60-78 years) and 524 of the study participants were men (76.4%). Of the 685 patients, 33.4% constituted the left main or proximal left anterior descending artery group and 66.6% the other-culprit-lesion location group. The left main or proximal left anterior descending artery group had worse outcomes compared with the other-culprit-lesion location group (56.8% vs 47.5%; P = .02 for the composite end point at 30 days and 59.8% vs 50.1%; P = .02 for death at 1 year). In both groups, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a reduced risk of the composite end point at 30 days (49.1% vs 64.3% and 44.1% vs 50.9%; P for interaction = .27). At 1 year, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a significantly reduced risk of death in the left main or proximal left anterior descending artery but not the other-culprit-lesion location group (50.0% vs 69.6%; P = .003 and 49.8% vs 50.4%; P = .89; P for interaction = 0.02). CONCLUSIONS AND RELEVANCEIn patients with multivessel disease with myocardial infarction and cardiogenic shock, a culprit lesion located in the left main or proximal left anterior descending artery vs other coronary segments was associated with worse outcomes. These patients may especially benefit from culprit-lesion-only percutaneous coronary intervention with optional staged revascularization, although further investigation is needed to confirm this finding.

Prognostic Utility of Culprit SYNTAX Score in Patients With Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction

“…CardShock substudy 13 also reported no difference between infarct-related arteries for mortality. In contrast to these two studies, a post hoc analysis 12 reported that patients with left main and proximal left anterior descending artery as a culprit lesion had worse mortality rates compared to those with the others and the right coronary artery was more frequent in the survivor group.…”

“…11 Prognostic role of culprit lesion was thought to be determined only by location, in previous studies. 12 −14 We postulated that the prognostic value of culprit-lesion SS (cul-SS) might be different from SS and nonculprit SS (ncul-SS) in patients with CS-STEMI. This study aimed to evaluate the predictive utility of cul-SS and other predictors for in-hospital mortality among patients with CS-STEMI.…”

Management of Non-Culprit Lesions in STEMI Patients with Multivessel Disease

“…Although the rates of rehospitalization for heart failure and repeat revascularization were higher in the culprit lesion-only revascularization group, mortality did not differ significantly between the two groups at one year. A post-hoc analysis of the CULPRIT-SHOCK trial showed that culprit lesion PCI vs. multivessel PCI resulted in a significantly lower risk of death and kidney replacement therapy at 30 days (45.6% vs. 63.5%; p = 0.007) and of mortality at 1 year (50% vs. 69.6%; p = 0.003) only in patients with a culprit lesion of the left main or proximal left anterior descending artery [ 54 ]. It is important to note the limitations of the trial in which only 28% of patients received a mechanical circulatory support device, including that 12% of the total cohort were supported with the transvalvular axial flow device Impella (Abiomed, Danvers, MA, USA).…”

Interventional treatment of acute myocardial infarction-related cardiogenic shock

“…1) [61]. Moreover, no clear evidence exists with regards to the prognostic value of distal versus proximal culprit location [56,62]. However, in the interpretation of these results, direct comparison should be done with caution as patient characteristics and management varies between studies.…”