LandmarkRCT

CULPRIT-SHOCK

PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock

New England Journal of Medicine, 2017 · Multicenter, randomized, open-label trial.

Clinical question

In cardiogenic shock with multivessel coronary disease, does culprit-lesion-only PCI (with optional staged revascularization) improve outcomes compared with immediate multivessel PCI?

Population: 706 patients with multivessel disease and cardiogenic shock complicating acute MI.
Intervention: Culprit-lesion-only PCI, with staged revascularization of other lesions if needed.
Comparator: Immediate multivessel PCI.
Primary outcome: Composite of 30-day death or severe renal failure requiring renal replacement therapy.
Result: Culprit-lesion-only PCI reduced the composite of 30-day death or severe renal failure compared with immediate multivessel PCI. (45.9% (culprit-only) vs 55.4% (multivessel))

What the trial found

An initial strategy of treating only the culprit lesion, rather than all significant lesions immediately, reduced 30-day death and severe renal failure in cardiogenic shock with multivessel disease.

Current guideline position

Current guidance favors culprit-lesion-only PCI as the initial strategy in cardiogenic shock with multivessel disease, based on this trial.

Clinical interpretation

This shifted practice away from treating all lesions at the index procedure in cardiogenic shock — the extra contrast load, procedure time, and hemodynamic stress of complete revascularization in an unstable patient appear to outweigh any benefit of immediately opening non-culprit vessels.

Limitations

Open-label design.
One-year follow-up (a separate report) showed no significant difference in mortality between strategies, narrowing the durability of the 30-day composite benefit.

High certainty

Clinical Context & Relevant Topics (1)

Disease Reference

Cardiogenic Shock

Primary pump failure, SCAI staging (A–E), PAC hemodynamics (CPO, PAPi), inotrope selection, emergent revascularization, and mechanical circulatory support.

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