culprit shock - pci strategies in patients with acute
TRANSCRIPT
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CULPRIT SHOCK PCI Strategies in Patients with Acute
Myocardial Infarction and Cardiogenic Shock
Dr O. BARTHELEMY
CHU Pitié Salpêtrière
APHP, Paris
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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
Ownership/Founder: None
Intellectual Property Rights: None
Other Financial Benefit: None
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The shock spiral
Reynolds Circ 08
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RCT in cardiogenic shock
Thiele et al. Eur Heart J 2015; 36: 1223-1230
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Prognosis of cardiogenic shock (AMI)
Aissaoui EHJ 2012
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Incidence of MultiVessel Disease in shock
Thiele NEJM 2012, Hochman NEJM 1999, The TRIUMPH investigators JAMA 2007, Hochman JACC 2000
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?
Culprit LesionOnly
Culprit lesiononly + Staged
Revasc.
Immediate MV-PCI
CABG
Cardiogenic
ShockMV-CAD
Revascularization strategies
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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
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MultiVessel PCI in shock
De Waha EHJ acute cardiovasc care 2017, epub
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Outcomes after MVPCI in shock
De Waha EHJ acute cardiovasc care 2017, epub
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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
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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
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Hypothesis
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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
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Endpoints
Thiele et al. AHJ 2016;172:160-169
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Baseline characteristics
Thiele et al. New Eng J Med 2017; epub october 30
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Procedural characteristics
Thiele et al. New Eng J Med 2017; epub october 30
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Primary Endpoint
Thiele et al. New Eng J Med 2017; epub october 30
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All cause mortality
Thiele et al. New Eng J Med 2017; epub october 30
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Renal Replacement Therapy
Thiele et al. New Eng J Med 2017; epub october 30
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SAPS II score
Thiele et al. New Eng J Med 2017; epub october 30
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Arterial Lactate
Thiele et al. New Eng J Med 2017; epub october 30
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Glomerular Filtration Rate
Thiele et al. New Eng J Med 2017; epub october 30
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Subgroup analysisPrimary Endpoint
Thiele et al. New Eng J Med 2017; epub october 30
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Conclusions
Thiele et al. New Eng J Med 2017; epub october 30
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80 57 45
600
55
302
398
0
100
200
300
400
500
600
700
SHO
CK
TRIU
MPH
SMASH
PRAG
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TAC
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I
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CU
LPR
IT-S
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CK
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atients
Patient Inclusions in Cardiogenic Shock Trials
Sto
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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