Myocardial Revascularization in Critical Patients with Acute Myocardial Infarction and Cardiogenic Shock – a Perspective on New European Recommendations

Patients with multivessel disease and acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the worst outcomes in the field of cardiac critical care, with mortality rates reported as high as 45– 50% even in the presence of the most modern facilities for advanced cardiac support.1 The main recent directions of development in the field of emergency care for critical patients with CS and AMI are represented by: the change introduced by the new European recommendations regarding the revascularization of culprit lesions only in patients with AMI and CS, the implementation of regional networks for reducing time delays from symptom onset to revascularization, and the use of modern equipment for advanced cardiac support.1–3 The first major change in the therapeutic strategy for CS-AMI patients is related to the recent change in the European recommendation for primary revascularization in patients with multivessel disease and CS complicating AMI. Several years ago, the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial demonstrated that emergency revascularization can significantly improve survival in patients with CS complicating AMI.2 However, in the presence of multivessel disease, there were inconclusive data to support the need for complete revascularization of all lesions in emergency conditions.3 Until recently, while major international guidelines recommended against urgent revascularization of non-culprit lesions in hemodynamically stable patients with STEMI, European guidelines recommended that revascularization of non-culprit arteries should be considered in patients with CS (indication class IIa).4 The recent guidelines on myocardial revascularization published by the European Society of Cardiology clearly advise against complete revascularization in patients with CS, recommending revascularization of the culprit lesion only (the lesion that caused infarction) and staged procedures for the non-culprit lesions.5 This change in recommendations is mainly caused by the recently published results of the CULPRIT-SHOCK trial, which demonstrated that in patients with multivessel disease, AMI, and CS, a strategy consisting in primary percutaneous coronary intervention (PCI) of the culprit lesion only is associated with a significant risk reduction in 30-day all-cause mortality (43.3% vs. 51.6%, HR = 0.84, p = 0.03) and with a significantly lower incidence of the composite endpoint consisting in all-cause mortality or severe renal failure, compared to a strategy consisting in complete revascularization of all coronary lesions in emergency.6 Therefore, the current guidelines published this year strongly recommend culprit lesion-only primary PCI in patients with CS complicating AMI. The second major direction for development in cardiac critical care for CS patients is represented by the efforts to implement appropriate logistics for reducing time deMyocardial Revascularization in Critical Patients with Acute Myocardial Infarction and Cardiogenic Shock – a Perspective on New European Recommendations