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Randomized Controlled Trial
. 2020 Dec 1;5(12):1329-1337.
doi: 10.1001/jamacardio.2020.3377.

Association of Culprit Lesion Location With Outcomes of Culprit-Lesion-Only vs Immediate Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock: A Post Hoc Analysis of a Randomized Clinical Trial

Serdar Farhan  1   2 , Birgit Vogel  1   2 , Gilles Montalescot  3 , Olivier Barthelemy  3 , Uwe Zeymer  4 , Steffen Desch  5 , Suzanne de Waha-Thiele  6 , Lars S Maier  7 , Marcus Sandri  5 , Ibrahim Akin  8 , Georg Fuernau  6 , Taoufik Ouarrak  4 , Marie Hauguel-Moreau  3 , Steffen Schneider  4 , Holger Thiele  5 , Kurt Huber  2   9
Affiliations
Randomized Controlled Trial

Association of Culprit Lesion Location With Outcomes of Culprit-Lesion-Only vs Immediate Multivessel Percutaneous Coronary Intervention in Cardiogenic Shock: A Post Hoc Analysis of a Randomized Clinical Trial

Serdar Farhan et al. JAMA Cardiol. .

Abstract

Importance: Myocardial infarction with a culprit lesion located in the left main or proximal left anterior descending artery compared with other coronary segments is associated with more myocardium at risk and worse clinical outcomes.

Objective: To evaluate the association of culprit lesion location with outcomes of culprit-lesion-only percutaneous coronary intervention with optional staged revascularization vs immediate multivessel percutaneous coronary intervention in patients with multivessel disease, myocardial infarction, and cardiogenic shock.

Design, setting, and participants: Post hoc analysis of the Culprit Lesion Only Coronary Intervention vs Multivessel Coronary Intervention in Cardiogenic Shock (CULPRIT-SHOCK), an investigator-initiated randomized, open-label clinical trial. Patients with multivessel disease, acute myocardial infarction, and cardiogenic shock were enrolled at 83 European centers from April 2013 through April 2017.

Interventions: Patients were randomized to culprit-lesion-only percutaneous coronary intervention with optional staged revascularization or immediate multivessel percutaneous coronary intervention (1:1). For this analysis, patients were stratified by culprit lesion location in the left main or proximal left anterior descending artery group and other-culprit-lesion location group.

Main outcomes and measures: End points included a composite of death or kidney replacement therapy at 30 days and death at 1 year.

Results: The median age of the study population was 70 (interquartile range, 60-78 years) and 524 of the study participants were men (76.4%). Of the 685 patients, 33.4% constituted the left main or proximal left anterior descending artery group and 66.6% the other-culprit-lesion location group. The left main or proximal left anterior descending artery group had worse outcomes compared with the other-culprit-lesion location group (56.8% vs 47.5%; P = .02 for the composite end point at 30 days and 59.8% vs 50.1%; P = .02 for death at 1 year). In both groups, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a reduced risk of the composite end point at 30 days (49.1% vs 64.3% and 44.1% vs 50.9%; P for interaction = .27). At 1 year, culprit-lesion-only vs immediate multivessel percutaneous coronary intervention was associated with a significantly reduced risk of death in the left main or proximal left anterior descending artery but not the other-culprit-lesion location group (50.0% vs 69.6%; P = .003 and 49.8% vs 50.4%; P = .89; P for interaction = 0.02).

Conclusions and relevance: In patients with multivessel disease with myocardial infarction and cardiogenic shock, a culprit lesion located in the left main or proximal left anterior descending artery vs other coronary segments was associated with worse outcomes. These patients may especially benefit from culprit-lesion-only percutaneous coronary intervention with optional staged revascularization, although further investigation is needed to confirm this finding.

Trial registration: ClinicalTrials.gov Identifier: NCT01927549.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr de Waha-Thiele reports grants from German Heart Research Foundation, German Cardiac Society, European Union, Seventh Framework programme (FP7/2007-2013) grant agreement n602202 during the conduct of the study. Dr Schneider reports grants from European Union during the conduct of the study. Dr Zeymer reports grants and personal fees from AstraZeneca, BMS, Pfizer, Bayer, and Novartis and personal fees from Boehringer Ingelheim, MSD, Sanofi, Trommsdorf, and Amgen outside the submitted work. Dr Montalescot reports personal fees from Abbott, American College of Cardiology Foundation, Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Daiichi-Sankyo, Menarini; grants from Actelion, Boehringer Ingelheim, Boston Scientific, Fédération Française de Cardiologie, ICAN, Idorsia, Lead-Up, Medtronic, MSD, Pfizer, Quantum Genomics, Sanofi, Servier; personal fees from Axis-Santé, Beth Israel Deaconess Medical, Brigham Women’s Hospital, China Heart House, Elsevier, Europa, Novo Nordisk, Occlutech, Partners, and WebMD outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flowchart
PCI indicates percutaneous coronary intervention; LM, left main coronary artery; pLAD, proximal left anterior descending artery.
Figure 2.
Figure 2.. Kaplan-Meier Curves Comparing 1-Year Mortality
A, Kaplan-Meier curve comparing 1-year mortality in left main (LM) or proximal left anterior descending artery (pLAD) culprit lesion (CL) location vs other CL location. B, Kaplan-Meier curve comparing 1-year mortality in patients with left main or pLAD CL location vs other CL location treated by culprit-lesion-only percutaneous coronary artery intervention (CL-PCI) with optional staged revascularization vs immediate multivessel percutaneous coronary artery intervention (MV-PCI).
See this image and copyright information in PMC

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