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Cardiogenic shock: a summary of the randomized SHOCK trial
1Division of Cardiology, St. Lukes-Roosevelt Hospital Center, Columbia University, 1111 Amsterdam Avenue, New York, NY 10025, USA. vmenon@slrhc.org
Insights
Early revascularization improves long-term survival for acute myocardial infarction patients with cardiogenic shock. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial showed benefits for patients under 75.
Area of Science:
- Cardiology
- Critical Care Medicine
Background:
- Cardiogenic shock is a major cause of mortality in acute myocardial infarction patients.
- Prompt intervention is crucial for improving outcomes in these critically ill individuals.
Purpose of the Study:
- To evaluate the efficacy of emergency revascularization versus initial medical stabilization in patients with cardiogenic shock following acute myocardial infarction.
Main Methods:
- The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial randomized 302 patients.
- Interventions included emergency revascularization (within 6 hours) or initial medical stabilization with potential delayed revascularization.
- Primary endpoint was 30-day all-cause mortality.
Main Results:
- No significant difference in 30-day mortality between groups (53% vs. 44%, p=0.109).
- Significant survival benefit observed at 6 and 12 months with early revascularization (50% vs. 37%; p=0.027 and 47% vs. 34%; p=0.025).
- Benefit was most pronounced in patients younger than 75 years.
Conclusions:
- Emergency revascularization does not improve short-term survival but offers significant long-term survival benefits for acute myocardial infarction patients with cardiogenic shock.
- Current guidelines recommend emergency revascularization for patients under 75 with cardiogenic shock based on SHOCK trial findings.
Abstract:
Cardiogenic shock is the most common cause of death for patients hospitalized with acute myocardial infarction. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial randomly assigned 302 patients with predominant left ventricular failure following an acute myocardial infarction to a strategy of emergency revascularization or initial medical stabilization. Emergency revascularization by either coronary artery bypass grafting or angioplasty was required within 6 hours of randomization. Patients assigned to initial medical stabilization could undergo delayed revascularization at a minimum of 54 hours post-randomization. The primary end point of the study was 30-day all-cause mortality. Overall survival at 30 days did not differ significantly between the emergency revascularization and initial medical stabilization groups (53% vs. 44%; p=0.109). However, at the 6- and 12-month follow-up, there was a significant survival benefit with early revascularization (50% vs. 37%; p=0.027 and 47% vs. 34%; p=0.025, respectively). The benefit appeared to be greatest for those less than 75 years of age, with 20 lives saved at 6 months per 100 patients treated. According to the results of the SHOCK trial, the American College of Cardiology/American Heart Association guidelines for myocardial infarction now recommend emergency revascularization for patients younger than 75 years with cardiogenic shock.