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Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction
Judith S Hochman1, Lynn A Sleeper, John G Webb
1Cardiovascular Clinical Research Center, New York University School of Medicine, New York 10016, USA. judith.hochman@med.nyu.edu
Insights
Early revascularization significantly improves long-term survival for acute myocardial infarction patients with cardiogenic shock. This strategy offers a 67% relative survival improvement at six years compared to initial medical stabilization.
Area of Science:
- Cardiology
- Interventional Cardiology
- Critical Care Medicine
Background:
- Cardiogenic shock (CS) is a primary cause of mortality in acute myocardial infarction (MI) patients.
- While 1-year survival is higher with early revascularization, long-term data are limited.
- The SHOCK trial investigated the long-term impact of early revascularization in CS complicating acute MI.
Purpose of the Study:
- To assess the effect of early revascularization on long-term survival in acute MI patients with CS.
- To compare long-term outcomes between early revascularization and initial medical stabilization strategies.
Main Methods:
- The international randomized SHOCK trial enrolled 302 patients with acute MI complicated by CS.
- Patients were randomized to early revascularization or initial medical stabilization.
- Long-term vital status follow-up was conducted annually until 2005 (1-11 years).
Main Results:
- The 13% survival advantage for early revascularization at 1 year persisted at 6 years (32.8% vs 19.6%).
- Early revascularization showed a significant survival benefit (HR 0.74, P=.03) over 6 years.
- Among hospital survivors, 6-year survival was higher with early revascularization (62.4% vs 44.4%).
Conclusions:
- Early revascularization significantly improves 6-year survival in acute MI patients with CS.
- This strategy resulted in a 13.2% absolute and 67% relative improvement in 6-year survival.
- Early revascularization is recommended for acute MI patients experiencing CS due to left ventricular failure.
Context:
Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction (MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking.
Objective:
To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI.
Design, Setting, And Patients:
The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock (mean [SD] age at randomization, 66 [11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years (median for survivors, 6 years).
Main Outcome Measures:
All-cause mortality during long-term follow-up.
Results:
The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years (13.1% and 13.2%, respectively; hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.97; log-rank P = .03). At 6 years, overall survival rates were 32.8% and 19.6% in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed (HR, 0.59; 95% CI, 0.36-0.95; P = .03). The 6-year survival rates for the hospital survivors were 62.4% vs 44.4% for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3% vs 14.3% and, for the 1-year survivors, 8.0% vs 10.7%. There was no significant interaction between any subgroup and treatment effect.
Conclusions:
In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2% absolute and a 67% relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.
Trial Registration:
clinicaltrials.gov Identifier: NCT00000552.
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