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CULPRIT-SHOCK: Culprit-only PCI maintains advantage at 1 year for cardiogenic shock, multivessel disease
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MUNICH — At 1 year, risk for death or renal replacement therapy was lower among patients with acute MI, cardiogenic shock and multivessel CAD who underwent culprit-lesion-only PCI compared with multivessel PCI, according to new data from the CULPRIT-SHOCK study.
However, the culprit-lesion-only PCI group had more repeat revascularizations and rehospitalizations for HF, and MI was similar in both groups. There was a trend toward lower mortality in the culprit-lesion-only PCI group.
As Cardiology Today’s Intervention previously reported, in the 706-patient, multicenter, randomized trial, the composite primary endpoint of death or renal-replacement therapy at 30 days occurred in fewer patients in the culprit-lesion-only PCI group vs. the multivessel PCI group (45.9% vs. 55.4%; RR = 0.83; 95% CI, 0.71-0.96).
Researchers reported 1-year results in a presentation at the European Society of Cardiology Congress. Holger Thiele, MD, from the Heart Center Leipzig at the University of Leipzig, Leipzig, Germany, said in a presentation that the difference in the primary outcome was maintained at 1 year (52% vs. 59.5%; RR = 0.87; 95% CI, 0.76-0.99).
The prespecified secondary endpoints at 1 year included all-cause death, recurrent MI, repeat revascularization, rehospitalization for congestive HF and a composite of death/MI/ rehospitalization for congestive HF.
At 1 year, all-cause mortality occurred in 50% of the culprit-lesion-only PCI group vs. 56.9% of the multivessel PCI group (RR = 0.88; 95% CI, 0.76-1.01), Thiele said, noting the initial 30-day significant difference in mortality was attenuated over time.
The groups displayed similar rates of recurrent MI (culprit-lesion-only group, 1.7%; multivessel PCI group, 2.1%; RR = 0.85; 95% CI, 0.29-2.5) and death/recurrent MI (culprit-lesion-only PCI group, 50.9%; multivessel PCI group, 58.4%; RR = 0.87; 95% CI, 0.76-1).
Repeat revascularization (32.3% vs. 9.4%; HR = 3.44; 95% CI, 2.39-4.95) and rehospitalization for congestive HF (5.2% vs. 1.2%; RR = 4.46; 95% CI, 1.53-13.04) were higher in the culprit-lesion-only group vs. the multivessel group.
“The 30-day difference in all-cause mortality was attenuated over time, as shown in a landmark analysis, but there was no increase in mortality after 30 days until 1-year follow-up,” Thiele said during a presentation. “Culprit-lesion-only PCI is possibly associated with an increase in heart failure hospitalizations, although the numbers were low. Not surprising was that it was also associated with more repeat revascularizations over 1-year follow-up. These data support the recent change in ESC guidelines,” in which immediate multivessel PCI in this population was downgraded.
The mean age in both groups was 70 years. Men comprised 75% of the culprit-lesion-only group and 78% of the multivessel PCI group. – by Erik Swain
Reference:
Thiele H, et al. Late-Breaking Science in Interventional Cardiology 1. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.
Thiele H, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1808788.
Disclosure: Thiele reports he receives grant and research support from the European Union and German Cardiac Society German Heart Research Foundation.
Perspective
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B. Hadley Wilson, MD, FACC
The initial excitement with the 30-day results of CULPRIT-SHOCK were supported by the 1-year results. At 30 days, there was less death and renal replacement therapy in patients who received culprit-artery-only PCI vs. multivessel PCI. At 1-year follow-up, the reduction in mortality was attenuated and no longer significant, but the primary composite endpoint of death and renal replacement therapy was still significant and sustained, prompting new ESC guidelines recommending culprit-lesion-only PCI as the default therapy with acute MI patients presenting with shock.
The higher rate of HF hospitalization in the culprit-lesion-only group is a little difficult to explain, but may relate to more in this group surviving to present with HF later, or alternatively, those with multivessel PCI may have improved early LV function and avoided subsequent HF.
In any event, these 1-year results overall support the change in guidelines and the practice of culprit-artery-only PCI in patients with acute MI and shock.
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