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Complete revascularisation or culprit artery only in cardiogenic shock: the real shock is the lack of data!
  1. Timothy D Henry,
  2. Abhimanyu (Manu) Uberoi
  1. Cedars-Sinai Heart Institute, Los Angeles, California, USA
  1. Correspondence to Dr Timothy D Henry, Department of Cardiology, Cedars-Sinai Heart Institute, 127 S. San Vicente Blvd., Suite A3100, Los Angeles, CA 90048, USA; henryt{at}cshs.org

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Approximately 40–65% of patients presenting with ST elevation myocardial infarction (STEMI) have multivessel disease (MVD). These patients have higher mortality and worse clinical outcomes than patients with STEMI with single vessel disease irrespective of haemodynamic status.1–3 Despite this common clinical scenario, the data available to guide management of these patients is remarkably sparse. The recommendations from the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) and the European Society of Cardiology (ESC) Guidelines have been stronger than the data supporting those guidelines, but that is changing.

For patients with STEMI presenting without cardiogenic shock, Percutaneous Coronary Intervention (PCI) of a non-culprit vessel is currently considered a class III indication, meaning the risk outweighs the benefit and the procedure SHOULD NOT be performed (not helpful and may be harmful). Despite the Class III indication, registries indicate 10–25% of patients with STEMI in fact undergo multivessel PCI. The recent publication of two randomised trials, Preventative Angioplasty in Acute Myocardial Infarction (PRAMI) and Complete Versus culprit-Lesion only PRimary PCI Trial (CvLPRIT), has dramatically changed our thinking for patients with STEMI with MVD and without cardiogenic shock.2 ,3 Both trials found complete revascularisation was associated with a reduction in major adverse cardiac events (MACE) compared with ‘culprit only’ PCI. Following successful primary PCI in the PRAMI trial, 465 patients with MVD were randomised to either ‘preventive PCI’ of all lesions ≥50% during the same setting or ‘culprit only’ PCI. The trial was stopped early due to a significantly lower MACE rate (composite of death from cardiac cause, non-fatal myocardial infarction (MI) or refractory angina) in the ‘preventive PCI’ arm (9% vs 23% in the ‘culprit only’ arm; p value <0.001). In the CvLPRIT trial, patients with successful PCI and MVD were randomised to PCI of all …

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