culprit shock - pci strategies in patients with acute

CULPRIT SHOCK PCI Strategies in Patients with Acute

Myocardial Infarction and Cardiogenic Shock

Dr O. BARTHELEMY

olivier.barthelemy@aphp.fr

CHU Pitié Salpêtrière

APHP, Paris

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

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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

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

Primary Endpoint

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

All cause mortality

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

Renal Replacement Therapy

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

SAPS II score

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

Arterial Lactate

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

Glomerular Filtration Rate

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

Subgroup analysisPrimary Endpoint

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

Conclusions

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

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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

III IIa IIb IIIIIIIII

II IIa IIb IIII IIII IIIIII

2012 2014

CULPRIT SHOCK challenges current ESC guidelines

III IIa IIb IIIIIIIII

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

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