Skip to content
evident
Original paper
2017NEJMCardiology

CULPRIT-SHOCK

PCI strategies in patients with acute myocardial infarction and cardiogenic shock

RCTCardiogenic shock

On this page

Overview

In MI with cardiogenic shock, culprit-only PCI beat immediate multivessel PCI for death or renal failure.

Clinical takeaway

CULPRIT-SHOCK changed cath-lab strategy in shock: stabilize the culprit lesion first rather than routinely fixing every stenosis immediately.

Key result

Death or renal-replacement therapy at 30 days was 45.9% with culprit-only PCI vs 55.4% with immediate multivessel PCI (RR 0.83, 95% CI 0.71-0.96; p=0.01).

Practice impact

Favor culprit-only PCI first in AMI cardiogenic shock with multivessel disease, with staged PCI when appropriate.

Evidence

Study design

Randomized open-label trial.

Enrollment

706

Follow-up

30 days for primary outcome.

Geography

Europe

Clinical question

In AMI with cardiogenic shock and multivessel disease, is culprit-only PCI better than immediate multivessel PCI?

Population

  • Patients with acute myocardial infarction, cardiogenic shock, and multivessel coronary artery disease.

Intervention

PCI of the culprit lesion only, with option for staged revascularization.

Comparator

Immediate multivessel PCI.

Primary outcome

Composite of death or severe renal failure requiring renal-replacement therapy at 30 days.

Culprit-lesion-only PCI reduced death or renal-replacement therapy compared with immediate multivessel PCI.

Relative risk / 0.83 / 95% CI 0.71-0.96 / p=0.01

Key results

  • Primary composite at 30 days: 158 of 344 (45.9%) with culprit-only PCI vs 189 of 341 (55.4%) with multivessel PCI; RR 0.83 (95% CI 0.71-0.96; p=0.01).
  • All-cause mortality was lower with culprit-only PCI at 30 days (RR 0.84, 95% CI 0.72-0.98; p=0.03).
  • Renal-replacement therapy was numerically lower with culprit-only PCI (RR 0.71, 95% CI 0.49-1.03; p=0.07).
  • Bleeding and stroke rates did not differ significantly between groups.

Harms

  • Leaving nonculprit lesions untreated initially can require staged revascularization.
  • PCI in shock carries contrast, bleeding, vascular, and hemodynamic risks.

Clinical Use

Practice impact

  • Shifted guidelines away from routine immediate multivessel PCI in AMI-related cardiogenic shock.

Applicability

  • AMI cardiogenic shock patients with multivessel coronary disease undergoing PCI.

Limitations

  • Does not apply to stable STEMI without shock, where complete revascularization evidence differs.
  • Anatomic exceptions may require individualized decisions.

Common misinterpretations

  • Do not apply CULPRIT-SHOCK to stable multivessel STEMI; shock changes the risk-benefit balance.

Related evidence

SHOCK - Earlier TrialCOMPLETE - Contrasting Result

Citation

Thiele H, Akin I, Sandri M, et al. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017;377(25):2419-2432. doi:10.1056/NEJMoa1710261

At 30 days, the composite primary end point of death or renal-replacement therapy had occurred in 158 of the 344 patients (45.9%) in the culprit-lesion-only PCI group and in 189 of the 341 patients (55.4%) in the multivessel PCI group (relative risk, 0.83; 95% confidence interval [CI], 0.71 to 0.96; P=0.01).