culprit shock - pci strategies in patients with acute
TRANSCRIPT
CULPRIT SHOCK PCI Strategies in Patients with Acute
Myocardial Infarction and Cardiogenic Shock
Dr O. BARTHELEMY
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
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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
?
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
80 57 45
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atients
Patient Inclusions in Cardiogenic Shock Trials
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II IIa IIb IIII IIII IIIIII
III IIa IIb IIIIIIIII
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