One-Year Survival Following Early Revascularization for Cardiogenic Shock - SHOCK trial

Description:

One-Year Survival Following Early Revascularization for Cardiogenic Shock.

Hypothesis:

To determine the effect of early revascularization on 1-year survival for patients presenting with cardiogenic shock.

Study Design

Study Design:

Patients Enrolled: 352

Drug/Procedures Used:

The study population included 352 patients with CS enrolled in the SHOCK trial. Of these, 152 patients were randomized to early revascularization (ERV) within 6 hours of randomization including angioplasty (55%) and coronary artery bypass graft surgery (CABG) (38%), and 150 patients were randomized to initial medical stabilization (IMS) including intra-aortic balloon counterpulsation (86%), thrombolysis (66%) and subsequent revascularization with PTCA or CABG permitted 54 hours or more after randomization (25%).

Principal Findings:

The 1-year survival was significantly higher in patients randomized to ERV when compared with patients randomized to IMS (46.7% vs. 33.6%, p< 0.03, RR for death, 0.72; 95% C.I., 0.54–0.95). A subgroup analysis revealed a significant treatment interaction with age (p = 0.03, age <75 vs. age ≥75 years). There was a significant survival benefit with ERV for patients <75 years old (1-year survival of 51.6% for ERV vs. 33.3% for IMS) and no significant benefit for patients ≥75 years old (1-year survival of 20.8% for ERV vs. 34.4% for IMS). There was no interaction with gender, randomization 6 hours or less after MI, anterior MI, diabetes mellitus, hypertension, US site, transfer and thrombolytic contraindication. At 1-year, 85% of patients in the ERV group and 80% of patients in the IMS group were NIHA congestive heart failure class I or II.

ERV results in a significant survival benefit at 1-year for patients presenting with acute MI complicated by CS.

Interpretation:

The SHOCK randomized trial can be considered a milestone in the treatment of patients with acute myocardial infarction complicated by CS. It confirms the survival benefit of ERV that had been in the past observed in registry studies, and it supports a strategy of ERV or of rapid transfer for ERV for patients with CS. The lack of benefit and possibly worse outcome observed in older patients suggest that a routine strategy of ERV should not be applied to this patient subgroup. However, a survival benefit was observed for elderly patients with ERV in the SHOCK registry. Thus, as the authors conclude, it is possible that careful case selection could results in improved outcomes also in this patient population.

References:

1. Hochman JS, Sleeper LA, White HD, et al. JAMA 2001; 285:190-2.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support , Hypertension

Keywords: Shock, Cardiogenic, Heart Failure, Coronary Artery Bypass, Angioplasty, Counterpulsation, Hypertension, Diabetes Mellitus


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