Received: 5 September 2017 | Revised: 6 September 2017 | Accepted: 11 September 2017 DOI: 10.1111/joic.12450 LETTER TO THE EDITOR Is index procedure complete revascularization really essential for ST-elevation myocardial infarction with cardiogenic shock? To the Editor, We have recently read the meta-analysis by Agarwal et al published in the journal with great interest. They concluded that a strategy of cardiovascular intervention with staged revascularization for multi- vessel ST-Elevation Myocardial Infarction (STEMI) was associated with lower mortality and no increase in repeat myocardial infarction and revascularization. However, patients with cardiogenic shock were excluded from the study. 1 Recently published 2017 European Society of Cardiology (ESC) guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation recom- mends intervention of non-infarct related artery in cardiogenic shock patients during index procedure (Class of recommendation IIa, Level of evidence C). 2 These recommendations solely depend on registry data and pathophysiological concerns in case of lack of randomized controlled trials. Most registries comparing staged multivessel interven- tion (MVI-S) versus index multivessel intervention (MVI-I) showed an increased mortality for the MVI-I approach. 3 In contrast to current guideline recommendation, a registry of cardiogenic shock patients with multivessel coronary artery disease presenting with acute myocardial infarction revealed that MVI-I was only performed in approximately one quarter of the patients. Furthermore and even more intriguingly, MVI-I as compared to MVI-S resulted in increased mortality according to the results of this prospective registry. 4 The prospective, randomized CULPRIT-SHOCK trial was designed to investigate immediate multi- vessel PCI in comparison to culprit lesion only PCI with potential staged PCI afterwards. 5 The study includes 706 patients to compare two treatment strategies about primary efficacy endpoint of 30-day mortality and renal failure necessitating renal replacement therapy. Safety endpoints are stroke and bleeding in this trial. Longer term (6 and 12 months) follow-up will also be applied. We think that staged multivessel intervention also seems to be logical approach in multivessel STEMI patients with cardiogenic shock. We will be able to understand better this issue in the near future. ORCID Ali Dogan http://orcid.org/0000-0002-4996-8165 Ali Dogan, MD Nuri Kurtoglu, MD Istanbul Yeni Yuzyil University, Faculty of Medicine, Department of Cardiology, Gaziosmanpasa Hospital, Gaziosmanpasa, Istanbul, Turkey Correspondence Ali Dogan, MD, Cardiologist, Istanbul Yeni Yuzyil University, Faculty of Medicine, Department of Cardiology, Gaziosmanpasa Hospital, Gaziosmanpasa, Istanbul 34245, Turkey. Email: drdali@hotmail.com REFERENCES 1. Agarwal N, Jain A, Garg J, et al. Staged versus index procedure complete revascularization in ST-elevation myocardial infarction: a meta-analysis. J Interv Cardiol. 2017;30:397–404. 2. Ibanez B, James S, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2017 Aug 26. https//doi.org/ 10.1093/eurheartj/ehx393 [Epub ahead of print]. 3. Pöss J, Desch S, Thiele H. Shock management in acute myocardial infarction. EuroIntervention. 2014;10:T74–T82. 4. Zeymer U, Hochadel M, Thiele H, et al. Immediate multivessel percutaneous coronary intervention versus culprit lesion intervention in patients with acute myocardial infarction complicated by cardiogenic shock: results of the ALKK-PCI registry. EuroIntervention. 2015;11: 280–285. 5. Thiele H, Desch S, Piek JJ, et al. Multivessel versus culprit lesion only percutaneous revascularization plus potential staged revascularization in patients with acute myocardial infarction complicated by cardiogenic shock: design and rationale of CULPRIT-SHOCK trial. Am Heart J. 2016;172:160–169. 112 | © 2018, Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/joic J Interven Cardiol. 2018;31:112.