LAUSR

Mortality of cardiogenic shock complicating myocardial infarction can be reduced by an early invasive strategy with percutaneous coronary intervention (PCI) of the infarct-related artery. Up to 80% of patients with cardiogenic shock present with multivessel coronary artery disease, and their mortality is higher compared with patients with single-vessel disease. Until recently, there were no randomized data on how to deal with nonculprit lesions in the setting of cardiogenic shock. This lack of evidence is also reflected by divergent recommendations in current international guidelines. The European ST-segment–elevation acute myocardial infarction (STEMI) guidelines, published in 2017, recommend immediate PCI of nonculprit lesions in patients with cardiogenic shock (Class IIb, Level of Evidence C),1 whereas the American STEMI guidelines give no specific recommendation.2 However, American appropriate use criteria, also published in 2017, consider immediate revascularization of a nonculprit artery during the same procedure appropriate if cardiogenic shock persists after treatment of the culprit artery.3 After publication of the randomized, multicenter CULPRIT-SHOCK trial (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock), guidelines and appropriate use criteria need to be reconsidered. To briefly recap, CULPRIT-SHOCK showed a significant clinical benefit of a culprit-lesion-only strategy with a reduction in the primary end point of 30-day mortality or severe renal failure requiring renal replacement therapy (45.9% culprit-lesion-only PCI versus 55.4% immediate multivessel PCI group; relative risk, 0.83; 95% confidence interval, 0.71–0.96; P =0.01), which was driven mainly by an absolute 8.2% reduction in 30-day mortality (43.3% versus 51.5%; relative risk, 0.84; 95% confidence interval, 0.72–0.98; P =0.03).4 With the application of current guideline criteria, the results …