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Background:Left main (LM) and proximal left anterior descending (LAD) are critical culprit lesion locations associated with worse clinical outcome in myocardial infarction without cardiogenic shock. In cardiogenic shock, data are controversial. In the CULPRIT-SHOCK trial, an independent angiographic core-laboratory reviewed all coronary angiograms to identify critical lesions and their location.Purpose:To assess whether critical coronary artery disease (CAD) location identifies a group of patients at poorer prognosis in patients presenting with acute myocardial infarction and cardiogenic shock.Methods:Critical CAD location was defined as >70% diameter stenosis of LM orof proximal LAD orLM equivalent (as >70% diameter of both proximal LAD and proximal Circ) or>70% diameter stenosis of a last remaining vessel. Patients with bypass grafts were excluded.Results:Among the 626 (91.3%) patients eligible for this CULPRIT SHOCK angiographic analysis, 269 (43.0%) were identified as having critical CAD location. Thirty eight patients (14.1%) had LM, 148 (55%) proximal LAD, 76 (28.3%) LM equivalent and 7 (2.6%) last remaining vessel lesions. In the critical CAD location group, death or renal replacement therapy within 30-day and death within 1-year were significantly higher than in the non-critical CAD location group (157 (58.4%) vs.155 (43.4%), p<0.001, 164 (61.0%) vs.159 (44.5%), p<0.001, respectively). These results were consistent in multivariate analysis. No interaction with the randomization group (culprit lesion-only or immediate multivessel PCI) was found (p=0.56 and p=0.11 respectively).Conclusion:In multivessel disease patients with cardiogenic shock related to acute myocardial infarction, critical CAD location (LM, LM equivalent, proximal LAD or last remaining vessel) - assessed by core-laboratory - was independently associated with worse clinical outcome at 30 days and 1 year.

Introduction:Validation lacks for the use of the TIMI Flow Grade (TFG) and TIMI Myocardial Perfusion grade (TMP) to estimate success of a percutaneous coronary intervention in shock patients with acute myocardial infarction.Hypothesis:We aimed at determining the prognostic insight of pre and post-PCI TFG and TMP in this context.Methods:CULPRIT SHOCK patients were included in the angiographic predictor analysis whenever their TFG or TMP was available in the Corelab database. A multivariable logistic regression analysis, adjusted on non-angiographic covariates, was performed to investigate if TFG or TMP separately or together, were independently associated with all-cause mortality. Results are presented as adjusted odds ratio (aOR) with 95% confidence intervals.Results:Data of 665 (96.9% of CULPRIT SHOCK study) patients were analysed. Pre-PCI TFG and TMP did not impact on mortality. When analysed in separate multivariable models, post-PCI TFG and TMP were both significantly associated with 30-day mortality: aOR 0.61 (95%CI: 0.38-0.97, p=0.037), and 0.46 (95%CI: 0.29-0.72, p<0.001), respectively. When considered in the same multivariable model, only TMP was significantly associated with 30-day mortality (adj. OR 0.38 [0.20-0.71], p=0.002) while TFG was not (p=0.51). Similarly, when included in the same multivariable model, only TMP remained associated with the 30-day composite of all-cause mortality and renal replacement therapy (aOR 0.34 [0.18-0.66], p=0.001) and mortality at 1 year follow-up (aOR 0.46 (0.24-0.88), p=0.02) while TFG was not (p=0.21 for both outcomes).Conclusions:The angiographic core laboratory post-PCI TFG and TMP parameters are associated with mortality after PCI in patients with acute myocardial infarction and cardiogenic shock. TMP appears to discriminate better the reperfusion success of PCI in terms of short- and long-term prognosis, suggesting that microcirculation matters more than the epicardial reperfusion after PCI in shock patients.

Background:Little is known about cardiogenic shock related to NSTEMI. OBJECTIVETo compare characteristics and outcomes of cardiogenic shock related to NSTEMI vs. STEMI and the effect modification of revascularization strategies.Methods:Patients with acute MI complicated by cardiogenic shock and multivessel disease of CULPRIT-SHOCK trial were stratified as presenting with STEMI or NSTEMI. The outcomes were 30-day mortality with and without renal-replacement therapy, and 1-year mortality. We evaluated the effect of the revascularization strategy- culprit-lesion-only PCI versus multivessel PCI - on outcomes according to the presentation.Results:Of the 664 patients of this analysis, 250 (37.7%) presented with NSTEMI and 414 (62.3%) with STEMI. Patients with NSTEMI were older (70.1?10.4 vs. 67.6?11.7 p=0.009), had more frequently diabetes (41.5% vs. 26.8% p<0.001) but smoked less (22.4% vs. 29.6%, p=0.05). Triple-vessel disease (71.2% vs. 59.1%, p=0.002) and chronic total occlusions (30.4% vs. 19.4%, p=0.001) were more frequent in NSTEMI. Compared with STEMI, NSTEMI patients had a longer hospitalization (20.0?71.2 vs. 10.6?33.2, p=0.02). While outcomes were not different at 30 days, mortality at 1 year was higher in NSTEMI patients (58.4% vs. 49.5%, crude OR 1.43; 95% CI 1.04-1.96; p=0.026) (Figure).When adjusted for risk factors, the 1-year mortality risk was not different (aOR: 1.28; 95 % 0.90-1.83; p=0.17). The ST presentation had no effect modification of culprit-lesion-only PCI vs. multivessel PCI for 30-day mortality or renal therapy replacement (pint=0.69), 30-day mortality (pint=0.65) and 1 year mortality (pint=0.49).Conclusions:Cardiogenic shock patients with multivessel disease and NSTEMI have more complex coronary lesions than STEMI patients. While their 1-year mortality rate was higher in the trial, the adjusted risk of death was similar. There was no effect modification of revascularization strategies on short- and long-term outcomes.