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Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should
J S Hochman1, L A Sleeper, J G Webb
1St. Luke's-Roosevelt Hospital Center and Columbia University, New York, NY 10025, USA.
Insights
Early revascularization for cardiogenic shock after myocardial infarction did not reduce 30-day mortality. However, this intervention showed a significant survival benefit at six months, suggesting its consideration in acute myocardial infarction patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Management
Background:
- Cardiogenic shock is a primary cause of mortality in acute myocardial infarction (AMI) patients.
- A randomized trial was conducted to assess the efficacy of early revascularization in patients experiencing cardiogenic shock.
Purpose of the Study:
- To evaluate the impact of early revascularization on mortality in patients with cardiogenic shock complicating AMI.
- To compare outcomes between emergency revascularization and initial medical stabilization.
Main Methods:
- Patients with cardiogenic shock were randomized to either emergency revascularization (n=152) or medical stabilization (n=150).
- Revascularization procedures included coronary-artery bypass grafting or angioplasty.
- Intraaortic balloon counterpulsation was utilized in 86% of patients in both groups.
- The primary endpoint was 30-day all-cause mortality; a secondary endpoint was 6-month survival.
Main Results:
- No significant difference in 30-day mortality between the revascularization (46.7%) and medical therapy (56.0%) groups (P=0.11).
- Six-month mortality was significantly lower in the revascularization group (50.3%) compared to the medical therapy group (63.1%) (P=0.027).
- Ninety-seven percent of patients assigned to revascularization underwent early angiography, with 87% receiving the intervention.
Conclusions:
- Emergency revascularization did not significantly reduce 30-day mortality in patients with cardiogenic shock.
- A significant survival benefit was observed at six months post-intervention.
- Early revascularization is a strong consideration for patients with AMI complicated by cardiogenic shock.
Background:
The leading cause of death in patients hospitalized for acute myocardial infarction is cardiogenic shock. We conducted a randomized trial to evaluate early revascularization in patients with cardiogenic shock.
Methods:
Patients with shock due to left ventricular failure complicating myocardial infarction were randomly assigned to emergency revascularization (152 patients) or initial medical stabilization (150 patients). Revascularization was accomplished by either coronary-artery bypass grafting or angioplasty. Intraaortic balloon counterpulsation was performed in 86 percent of the patients in both groups. The primary end point was mortality from all causes at 30 days. Six-month survival was a secondary end point.
Results:
The mean age of the patients was 66+/-10 years, 32 percent were women and 55 percent were transferred from other hospitals. The median time to the onset of shock was 5.6 hours after infarction, and most infarcts were anterior in location. Ninety-seven percent of the patients assigned to revascularization underwent early coronary angiography, and 87 percent underwent revascularization; only 2.7 percent of the patients assigned to medical therapy crossed over to early revascularization without clinical indication. Overall mortality at 30 days did not differ significantly between the revascularization and medical-therapy groups (46.7 percent and 56.0 percent, respectively; difference, -9.3 percent; 95 percent confidence interval for the difference, -20.5 to 1.9 percent; P=0.11). Six-month mortality was lower in the revascularization group than in the medical-therapy group (50.3 percent vs. 63.1 percent, P=0.027).
Conclusions:
In patients with cardiogenic shock, emergency revascularization did not significantly reduce overall mortality at 30 days. However, after six months there was a significant survival benefit. Early revascularization should be strongly considered for patients with acute myocardial infarction complicated by cardiogenic shock.