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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK: an international randomized trial of
J S Hochman1, L A Sleeper, E Godfrey
1St. Luke's-Roosevelt Hospital, Columbia University, New York, USA. jsh4@columbia.edu
Insights
Emergency revascularization in acute myocardial infarction (MI) patients with cardiogenic shock (CS) may reduce mortality. The SHOCK trial investigated this invasive strategy versus initial medical stabilization for CS complicating MI.
Area of Science:
- Cardiology
- Critical Care Medicine
- Interventional Cardiology
Background:
- Cardiogenic shock (CS) is a critical complication of acute myocardial infarction (MI), representing the leading cause of mortality in hospitalized MI patients.
- Previous nonrandomized studies indicated a potential survival benefit associated with revascularization in CS patients.
Purpose of the Study:
- To test the hypothesis that an early invasive strategy of emergency revascularization reduces 30-day mortality in patients with CS complicating acute MI compared to initial medical stabilization.
- To evaluate the impact of revascularization on mortality and other clinical outcomes in this high-risk patient population.
Main Methods:
- The Study of the Effectiveness of Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction (SHOCK) trial was a multicenter, randomized, unblinded study.
- Patients with CS complicating acute MI within 36 hours, confirmed hemodynamically, and without other shock causes were eligible.
- The invasive arm underwent immediate angiography and revascularization (PCI or CABG), while the medical stabilization arm received initial medical therapy, with potential delayed revascularization.
Main Results:
- The primary endpoint was 30-day all-cause mortality.
- Secondary endpoints included long-term mortality, changes in left ventricular function, and quality of life assessments.
Conclusions:
- The SHOCK trial aimed to determine if early revascularization improves survival in cardiogenic shock post-MI.
- Results from the SHOCK trial are crucial for guiding treatment strategies in this complex patient group.
Background:
Cardiogenic shock (CS) is the leading cause of death in patients hospitalized with acute myocardial infarction (MI). Nonrandomized studies suggest reduced mortality rate with revascularization.
Trial Design:
The SHOCK trial is a multicenter, randomized, and unblinded study with a Registry for trial-eligible and ineligible nonrandomized patients. The trial is testing the hypothesis that a direct invasive strategy of emergency revascularization for patients with cardiogenic shock complicating acute MI will reduce 30-day all-cause mortality rate by 20 absolute percentage points compared with initial medical stabilization. Eligibility criteria include development of CS within 36 hours of an acute transmural MI as evidenced by ST elevation or new left bundle branch block MI; clinical criteria for CS with hemodynamic confirmation; absence of a mechanical, iatrogenic, or other cause of shock; and enrollment within 12 hours of CS diagnosis. Patients randomly assigned to emergency revascularization immediately undergo coronary angiography, with percutaneous transluminal coronary angioplasty or coronary artery bypass grafting depending on the coronary anatomy. Patients assigned to initial medical stabilization may undergo revascularization >/=54 hours after randomization.
End Points:
The primary end point is all-cause 30-day mortality after randomization. Secondary end points include death at trial termination, changes in left ventricular dimensions and function measured by echocardiography at randomization and 2 weeks later, and changes in quality of life and physical functioning from 2 weeks after discharge to 6 months after MI.
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