Invasive treatment in STEMI: PCI of the culprit vessel vs a multivessel approach

2018-08-10
Zaza Iakobishvili

Which invasive treatment strategy is preferred in ST-segment elevation myocardial infarction (STEMI): percutaneous coronary intervention (PCI) of the infarct-related artery only or revascularization of all significant lesions?

Zaza Iakobishvili, MD, PhD: Doing multivessel PCI during STEMI presentation was a class III [recommendation], so it was actually contraindicated. In some studies, small studies I have to mention—it is a primary culprit study—cardiologists feel more liberated from these things, and there are some situations when you can do a multivessel intervention, or during the primary PCI itself.1,2 But most of us are doing these interventions—primary PCI on the culprit vessel only—at an early stage, and 2 or 3 days apart during the same hospitalization we do the job with other severely narrowed arteries.

On the other hand, in cardiogenic shock patients where the multivessel PCI was considered to be standard of care but only on expert opinion, actually this view was challenged—it was even written in the recent guidelines that multivessel PCI by expert opinion should be the routine strategy for cardiogenic shock that complicates STEMI. A study that comes from Germany—a multicenter European study—shows very clearly that the 30-day mortality and renal replacement therapy composite outcome was better in patients who underwent the culprit vessel–only intervention than in patients who underwent multivessel intervention.3 It challenges these guidelines and probably the guidelines must be changed according to this study.

[After the recording of this interview, the European Society of Cardiology guidelines task force published their viewpoint, which incorporates the CULPRIT-SHOCK results in clinical practice.4]

References

1 Wald DS, Morris JK, Wald NJ, et al; PRAMI Investigators. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013 Sep 19;369(12):1115-23. doi: 10.1056/NEJMoa1305520. Epub 2013 Sep 1. PubMed PMID: 23991625.
2 Kelly DJ, McCann GP, Blackman D, et al. Complete Versus culprit-Lesion only PRimary PCI Trial (CVLPRIT): a multicentre trial testing management strategies when multivessel disease is detected at the time of primary PCI: rationale and design. EuroIntervention. 2013 Feb 22;8(10):1190-8. doi: 10.4244/EIJV8I10A183. PubMed PMID: 23425543.
3 Geisler T, Landmesser U, Skurk C, et al; CULPRIT-SHOCK Investigators. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017 Dec 21;377(25):2419-2432. doi: 10.1056/NEJMoa1710261. Epub 2017 Oct 30. PubMed PMID: 29083953.
4 Ibanez B, Halvorsen S, Roffi M, et al. Integrating the results of the CULPRIT-SHOCK trial in the 2017 ESC ST-elevation myocardial infarction guidelines: viewpoint of the task force. Eur Heart J. 2018 May 29. doi: 10.1093/eurheartj/ehy294. [Epub ahead of print] PubMed PMID: 29850788.
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