Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock? - SHOCK

Jul 10, 2003
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Date Published:
01/01/1995
Date Updated:
07/10/2003
Original Posted Date:
07/10/2003
References

Description:

Early revascularization for acute MI with cardiogenic shock.

Hypothesis:

To examine the proportion of patients with cardiogenic shock who are potential candidates for a trial of early revascularization, and the apparent impact of early revascularization.

Study Design

Study Design:

Patients Screened: 251
Patients Enrolled: 214
Mean Patient Age: 67.5
Female: 43

Patient Populations:

Systolic blood pressure (BP) persistently ≤90 mm Hg or vasopressors required to maintain BP >90 mmHg,
Evidence of end organ hypoperfusion
Evidence of elevated filling pressures

Exclusions:

Concurrent severe valvular heart disease, hemorrhage, or sepsis
Isolated right ventricular shock.

Primary Endpoints:

Overall in-hospital mortality

Drug/Procedures Used:

Thrombolytic therapy, primary angioplasty, intra-aortic counterpulsation balloon (IABP)

Principal Findings:

The overall in-hospital mortality was 66%. Overall mortality was significantly greater in patients aged 65 years or over when compared with that of patients under 65 years (72% versus 56%, P=.017).

Patients who received thrombolytic agents had mortality similar to thrombolytic agent eligible patients not receiving therapy (61% versus 71%, P=.334).

Patients clinically selected to undergo cardiac catheterization were significantly younger and had a lower mortality than those not selected (51% versus 85%, P<.0001) even if they were not revascularized (58%).

Among 47 patients who underwent PTCA, mortality rates did not differ by IABP use (62% with IABP versus 54% without IABP, P=.743). The success rate of PTCA in patients with cardiogenic shock was 69%.The mortality rate was 61% in patients with successful PTCA and 73% in patients with unsuccessful PTCA.

Mortality was significantly lower with the use of IABP (72% without IABP versus 57% with IABP, P=.039, n=173) in an unadjusted analysis. However, patients with IABP were younger and more often underwent cardiac catheterization. After adjusting for cardiac catheterization status, there was no significant association between mortality and IABP.

The median time to shock diagnosis after MI was 8 hours.

Interpretation:

Cardiogenic shock remains the leading cause of death in patients hospitalized with acute myocardial infarction (MI). In this registry, survival after early revascularization could not be predicted by readily available clinical parameters. The age, sex, MI location, timing of shock onset, and timing of revascularization were the same in survivors and nonsurvivors after early revascularization. Emergent PTCA and CABG are promising modalities for treatment of cardiogenic shock complicating acute MI. Whether they reduce mortality and which subgroups could potentially benefit most remain to be determined in ongoing randomized clinical trials.

References:

1. Circulation 1995;91:873-881. Pilot Registry results

Keywords: Survivors, Cause of Death, Shock, Cardiogenic, Thrombolytic Therapy, Hospital Mortality, Cardiac Catheterization, Blood Pressure, Fibrinolytic Agents, Angioplasty, Counterpulsation


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