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Evevident
Original paper
2017NEJMCardiology

CULPRIT-SHOCK

PCI strategies in patients with acute myocardial infarction and cardiogenic shock

RCTCardiogenic shock

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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 lower with culprit-only PCI.

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 / CI 95% CI 0.71-0.96 / p=0.01

Key results

  • Primary composite was lower with culprit-only PCI.
  • All-cause mortality was lower with culprit-only PCI at 30 days.
  • Renal-replacement therapy was numerically lower with culprit-only PCI.

Harms

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

Clinical Use

When to cite

  • When deciding culprit-only versus multivessel PCI during AMI cardiogenic shock.

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