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Randomized trial of complete vs. culprit-only revascularization in STEMI patients with cardiogenic shock and non-CTO multi-vessel disease

Mohamed Atef Hamza, Tarek Abdelsalam, Nabil Farag, Islam Y Elgendy, Ahmed Rezq, Mostafa ElNozahi

Background: Clinical trials favor complete revascularization of non-culprit lesions in patients with STEMI and multivessel disease (MVD) over culprit only, however management of patients complicated by cardiogenic shock is still debatable.

Objectives: To study whether complete revascularization approach is better than culprit-only treatment STEMI patients with cardiogenic shock when excluding Chronic Total Occlusions (CTOs).

Methods: One hundred STEMI patients with cardiogenic shock and MVD were randomized to either culprit-only treatment (n=50) or complete revascularization (n=50) in the same sitting of Primary Percutaneous Coronary Intervention (PPCI). The primary endpoint was the incidence of Major Adverse Cardiac Events (MACE) at 6 months.

Results: Complete revascularization significantly reduced the rates of total MACE (38% vs. 66%; RR 0.58, 95% CI 0.38-0.86, p=0.005), all-cause mortality (32% vs. 52%; RR 0.62, 95% CI 0.38-0.99, p=0.033), with improvement in ejection fraction (44.2% vs. 33.0%, p=0.034), and lower rates of urgent revascularization (2% vs. 18%, p=0.008) when compared to culprit-only. There was no significant difference in the safety endpoints of stroke, contrast-induced nephropathy, major or minor bleeding between the groups.

Conclusion: In STEMI patients with cardiogenic shock and MVD, complete revascularization reduced the risk of mortality and total MACE when compared with culprit vessel only PCI, when excluding CTO lesions.