CULPRIT SHOCK - PCI Strategies in Patients with Acute

CULPRIT SHOCK PCI Strategies in Patients with Acute

Myocardial Infarction and Cardiogenic Shock

Dr O. BARTHELEMY

[email protected]

CHU Pitié Salpêtrière

APHP, Paris

mailto:[email protected]

Disclosure Statement of Financial Interest

I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company :

Grant/Research Support: None

Consulting Fees/Honoraria: None

Major Stock Shareholder/Equity: None

Royalty Income: None

Ownership/Founder: None

Intellectual Property Rights: None

Other Financial Benefit: None

The shock spiral

Reynolds Circ 08

RCT in cardiogenic shock

Thiele et al. Eur Heart J 2015; 36: 1223-1230

Prognosis of cardiogenic shock (AMI)

Aissaoui EHJ 2012

Incidence of MultiVessel Disease in shock

Thiele NEJM 2012, Hochman NEJM 1999, The TRIUMPH investigators JAMA 2007, Hochman JACC 2000

?

Culprit LesionOnly

Culprit lesiononly + Staged

Revasc.

Immediate MV-PCI

CABG

Cardiogenic

ShockMV-CAD

Revascularization strategies

MultiVessel PCI in cardiogenic shock2017 European and American guidelines

Ibanez et al. ESC STEMI Guidelines 2017. EHJ 2017; epub. Levine et al. JACC 2016; 67:1235-1250. Patel et al. JACC 2016; in press

MultiVessel PCI in shock

De Waha EHJ acute cardiovasc care 2017, epub

Outcomes after MVPCI in shock

De Waha EHJ acute cardiovasc care 2017, epub

Multivessel PCI in AMI (without shock)

PRAMI

DANAMI-3 COMPARE ACUTE

Wald NEJM 2013, Gershlick JACC 2015, Engstrom Lancet 2015, Smits NEJM 2017

CVLPRIT

MVPCI in AMI: Significantly reduce the primary endpoint

(composite) Mainly by decreasing the need of subsequent

revascularization No difference in death or MI (except in PRAMI)

PRAMI

CULPRIT SHOCK

PI + CoordinationHolger Thiele

National CoordinatorsKurt Huber

Gilles Montalescot

Jan Piek

Holger Thiele

Pranas Serpytis

Janina Stepinska

Christiaan Vrints

Marko Noc

Keith Oldroyd

Stefan Windecker

Stefano Savonitto

Thiele et al. AHJ 2016;172:160-169

Investigator-initiated European multicenter trial; 1:1 randomization

Hypothesis

30-day follow up

Primary Endpoint:

Mortality and/or

Severe renal failure 30 days

CULPRIT-SHOCK Flow chart

Patients in cardiogenic shock

after AMI N=1075

N= 344

Culprit Lesion only PCI +

potential staged

RevascularizationN=351

Check In- and exclusion criteria

Informed consent

(4 different versions)

Randomization

N=706

N= 341

Immediate Multivessel PCI

N=355

Not suitable:

CULPRIT-SHOCK

Registry

Thiele et al. AHJ 2016;172:160-169

Endpoints

Thiele et al. AHJ 2016;172:160-169

Baseline characteristics

Thiele et al. New Eng J Med 2017; epub october 30

Procedural characteristics


Primary Endpoint


All cause mortality


Renal Replacement Therapy


SAPS II score


Arterial Lactate


Glomerular Filtration Rate


Subgroup analysisPrimary Endpoint


Conclusions


80 57 45

600

55

302

398

0

100

200

300

400

500

600

700

SHO

CK

TRIU

MPH

SMASH

PRAG

UE -7

TAC

TIC

S

IABP-S

HO

CK

I

IABP-S

HO

CK

II

CU

LPR

IT-S

HO

CK

N P

atients

Patient Inclusions in Cardiogenic Shock Trials

Sto

p –

no

effe

ct

Sto

p s

low

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cru

itm

ent

Un

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rpo

we

red

Surr

ogate

endpoin

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706

Sto

p –

slo

w r

ecru

itm

ent

II IIa IIb IIII IIII IIIIII

III IIa IIb IIIIIIIII

STEMI with shock

Steg et al. Eur Heart J. 2012;33:2569-2619. Wijns et al. Eur Heart J 2010;31:2501-2555. Windecker et al. Eur Heart J. 2014; 35:2541-2619


II IIa IIb IIII IIII IIIIII

2012 2014

CULPRIT SHOCK challenges current ESC guidelines


2017

STEMI without shock

Ibanez et al. ESC STEMI Guidelines 2017. EHJ 2017; epub. Levine et al. JACC 2016; 67:1235-1250. Patel et al. JACC 2016; in press

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nejm.org


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CULPRIT SHOCK - PCI Strategies in Patients with Acute