More than half of patients with infarct-related cardiogenic shock (CS) also experienced cardiac arrest (CA), which a new analysis of the CULPRIT-SHOCK randomized trial shows was an independent predictor of mortality at 1-year follow-up. Consistent with the findings of the main trial, percutaneous coronary intervention (PCI) of only the culprit lesion was the preferred strategy over immediate multivessel PCI whether or not patients experienced CA, the analysis shows. These findings were reported by Uwe Zeymer, MD, of Klinikum Ludwigshafen, Germany, and colleagues in a manuscript published Monday online and in the March 28 issue of the Journal of the American College of Cardiology. The CULPRIT-SHOCK trial showed a lower rate of both the composite primary endpoint of 30-day mortality or severe renal failure and of 30-day mortality alone in patients who underwent culprit-lesion-only PCI in comparison with patients who underwent immediate multivessel PCI. CA has been associated with a poorer prognosis among patients with infarct-related CS, and a 2013 study suggested that in patients with multivessel disease presenting with CS and CA, immediate multivessel PCI was associated with increased survival. Zeymer and colleagues, therefore, conducted this secondary analysis of CULPRIT-SHOCK trial data to investigate the effect of CA on patients with multivessel disease undergoing culprit-lesion-only PCI vs. immediate multivessel revascularization. The analysis included 1,015 patients (683 in the randomized trial and 332 in a parallel registry), of whom 550 (54.2%) had CA. In comparison with patients without CA, patients with CA were younger (median age 65 years [interquartile ratio (IQR): 56-75) and were more likely to be male (78.9% vs. 70.3%; p=0.002). Patients with CA also had lower rates of hypertension, diabetes, family history of coronary artery disease, prior stroke, known peripheral artery disease, renal dysfunction and left main disease; and patients with CA showed signs of impaired organ perfusion. The composite of all-cause mortality or severe renal failure at 30 days occurred in 51.2% of patients in the CA group and in 48.5% of patients without CA (hazard ratio [HR]: 1.05; 95% confidence interval [CI]: 0.89-1.25). At 1 year, 53.8% of the patients with CA died, as did 50.3% of those without CA (p=0.29). A Cox multivariate analysis showed a significantly increased risk of death at 1 year in the CA group (HR: 1.27; 95% CI: 1.01-1.59; p=0.002). Also, culprit-lesion-only PCI showed a significantly lower risk of mortality than immediate multivessel revascularization in patients without CA at 30 days (HR: 0.70; 95% CI: 0.51-0.97) and 1 year (HR: 0.71; 95% CI: 0.52-0.96), but there was no significant difference in mortality risk between the two revascularization strategies in patients with CA at 30 days (HR: 0.89; 95% CI: 0.66-1.20) and 1 year (HR: 0.94; 95% CI: 0.71-1.25). However, the authors pointed out that p-values for interaction between patients with and without CA at 30 days (p for interaction = 0.47) and at 1 year (p for interaction = 0.28) does not suggest any significant difference between the groups. Based on this statistical finding, the authors concluded that culprit-lesion-only PCI is the better strategy in patients with multivessel disease and CS with or without CA. The study’s limitations included that it is a post hoc analysis and that the outcome of CA can be influenced by several factors that were not measured in the analysis, the authors wrote. They added that the benefits of culprit-lesion-only PCI are limited to patients who underwent 30 minutes or less of CPR because the randomized trial excluded patients who underwent CPR for more than 30 minutes. In an accompanying editorial, Alexander G. Truesdell, MD, Aditya Mehta, MD, and Lindsey A. Cilia, MD, all of the Inova Heart and Vascular Institute, Falls Church, Virginia, wrote that the analysis highlights “the high incidence of CA complicating AMI [acute myocardial infarction] CS and the persistently suboptimal outcomes with these conditions in isolation and together.” The editorialists added that the role of several other facts need to be evaluated in larger randomized trials, including targeted temperature management and mechanical circulatory support. “For now, although CLO [culprit-lesion-only] PCI should remain the ‘simple’ standard of care for AMI CS patients with or without CA, many other complexities of AMI with CS and CA still require significant further investigation,” the editorialists concluded. The analysis was supported by grants from the European Union Seventh Framework Program, the German Heart Research Foundation and the German Cardiac Society. The German Center for Cardiovascular Research also provided support. Sources: Zeymer U, Alushi B, Noc M, et al. Influence of Culprit Lesion Intervention on Outcomes in Infarct-Related Cardiogenic Shock With Cardiac Arrest. J Am Coll Cardiol 2023;81:1165–1176. Truesdell AG, Mehta A, Cilia LA. Myocardial Infarction, Cardiogenic Shock, and Cardiac Arrest Management Made Simple, But Not Too Simple. J Am Coll Cardiol 2023;81:1177–1180. Image Credit: Photographee.eu – stock.adobe.com