One-year survival following early revascularization for cardiogenic shock.

By Judith S. Hochman, Lynn A. Sleeper, Harvey D. White. Journal of the American Medical Association (JAMA), 2001

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CONTEXT Cardiogenic shock (CS) is the leading cause of death for patients hospitalized with acute myocardial infarction (AMI). OBJECTIVE To assess the effect of early revascularization (ERV) on 1-year survival for patients with AMI complicated by CS. DESIGN The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) Trial, an unblinded, randomized controlled trial from April 1993 through November 1998. SETTING Thirty-six referral centers with angioplasty and cardiac surgery facilities. PATIENTS Three hundred two patients with AMI and CS due to predominant left ventricular failure who met specified clinical and hemodynamic criteria. INTERVENTIONS Patients were randomly assigned to an initial medical stabilization (IMS; n = 150) group, which included thrombolysis (63% of patients), intra-aortic balloon counterpulsation (86%), and subsequent revascularization (25%), or to an ERV group (n = 152), which mandated revascularization within 6 hours of randomization and included angioplasty (55%) and coronary artery bypass graft surgery (38%). MAIN OUTCOME MEASURES All-cause mortality and functional status at 1 year, compared between the ERV and IMS groups. RESULTS One-year survival was 46.7% for patients in the ERV group compared with 33.6% in the IMS group (absolute difference in survival, 13.2%; 95% confidence interval [CI], 2.2%-24.1%; P<.03; relative risk for death, 0.72; 95% CI, 0.54-0.95). Of the 10 prespecified subgroup analyses, only age (<75 vs >/= 75 years) interacted significantly (P<.03) with treatment in that treatment benefit was apparent only for patients younger than 75 years (51.6% survival in ERV group vs 33.3% in IMS group). Eighty-three percent of 1-year survivors (85% of ERV group and 80% of IMS group) were in New York Heart Association class I or II. CONCLUSIONS For patients with AMI complicated by CS, ERV resulted in improved 1-year survival. We recommend rapid transfer of patients with AMI complicated by CS, particularly those younger than 75 years, to medical centers capable of providing early angiography and revascularization procedures.

Subfields: Cardiology and Cardiovascular Medicine, Surgery

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Citations in the corpus

Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. (2008, background): “Emergency PCI or surgery may be life-saving and should be considered at an early stage.(43,116) If neither of these are available or can only be provided after a long delay, fibrinolytic therapy should be given.”
Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. (2006, result): “We previously reported the initial and 1-year results of the randomized Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial.(5,6) This trial demonstrated that a strategy of early revascularization in patients with cardiogenic shock resulted in a nonsignificant ”
ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to update the 2001 Guidelines for Percutaneous Coronary Intervention (2006, background): “6 and is a class I, level of evidence A recommendation for patients younger than 75 years old and a class IIa, level of evidence B recommendation for those aged 75 years and older) (49).”
2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. (2008, background): “The SHOCK (SHould we emergently evascularize Occluded Coronaries for cardiogenic shocK) tudy (43) found that approximately 20% of all cardiogenic hock complicating MI was associated with NSTEMI.”