Abstract
BACKGROUND In patients who have acute myocardial infarction with cardiogenic shock, early revascularization of the culprit artery by means of percutaneous coronary intervention (PCI) improves outcomes. However, the majority of patients with cardiogenic shock have multivessel disease, and whether PCI should be performed immediately for stenoses in nonculprit arteries is controversial. METHODS In this multicenter trial, we randomly assigned 706 patients who had multivessel disease, acute myocardial infarction, and cardiogenic shock to one of two initial revascularization strategies: either PCI of the culprit lesion only, with the option of staged revascularization of nonculprit lesions, or immediate multivessel PCI. The primary end point was a composite of death or severe renal failure leading to renal-replacement therapy within 30 days after randomization. Safety end points included bleeding and stroke. RESULTS 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). The relative risk of death in the culprit-lesion-only PCI group as compared with the multivessel PCI group was 0.84 (95% CI, 0.72 to 0.98; P=0.03), and the relative risk of renal-replacement therapy was 0.71 (95% CI, 0.49 to 1.03; P=0.07). The time to hemodynamic stabilization, the risk of catecholamine therapy and the duration of such therapy, the levels of troponin T and creatine kinase, and the rates of bleeding and stroke did not differ significantly between the two groups. CONCLUSIONS Among patients who had multivessel coronary artery disease and acute myocardial infarction with cardiogenic shock, the 30-day risk of a composite of death or severe renal failure leading to renal-replacement therapy was lower among those who initially underwent PCI of the culprit lesion only than among those who underwent immediate multivessel PCI.
| Original language | English |
|---|---|
| Journal | New England Journal of Medicine |
| Volume | 377 |
| Issue number | 25 |
| Pages (from-to) | 2419-2432 |
| Number of pages | 14 |
| ISSN | 0028-4793 |
| DOIs | |
| Publication status | Published - 21.12.2017 |
Funding
Supported by a grant (FP7/2007-2013) from the European Union 7th Framework Program and by the German Heart Research Foundation and the German Cardiac Society. Dr. Landmesser reports receiving lecture fees and advisory-board fees from Abbott and Biotronik and grant support from the German Center for Cardiovascular Research; Dr. Piek, receiving travel support from Abbott Vascular and advisory-board fees and travel support from Philips Volcano; Dr. Noc, receiving consulting fees from ZOLL Circulation, lecture fees from Maquet Getinge, and grant support from AstraZeneca; Dr. Goslar, receiving lecture fees from AstraZeneca; Dr. Mon-talescot, receiving grant support paid to his institution, consulting fees, advisory-board fees, and lecture fees from Am-gen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, Medtronic, Merck Sharpe and Dohme, Pfizer, and Sanofi, grant support paid to his institution from Celladon, consulting fees from Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Menarini, the TIMI Study Group, and Actelion, lecture fees and education fees from the Cardiovascular Research Foundation, DME Resources, Europa, Lead-Up, WebMD, and Agence CCC, and review fees and education fees from Elsevier; Dr. Windecker, receiving grant support from Biotronik, Boston Scientific, Bracco, Edwards Lifesciences, Medtronic, Terumo, and St. Jude Medical; Dr. Savonitto, receiving grant support from Novartis, Daiichi Sankyo, and Eli Lilly and lecture fees from Pfizer, Bristol-Myers Squibb, AstraZeneca, and Bayer; and Dr. Zeymer, receiving lecture fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Novartis, Sanofi, MSD, The Medicines Company, Pfizer, Daiichi Sankyo, Eli Lilly, and Abiomed. No other potential conflict of interest relevant to this article was reported.
Research Areas and Centers
- Academic Focus: Center for Brain, Behavior and Metabolism (CBBM)
