Prognosis in cardiogenic shock after acute myocardial infarction in the interventional era.
OBJECTIVE
The purpose of this study is to describe the outcome in cardiogenic shock treated with aggressive reperfusion therapy and to identify factors predictive of in-hospital and long-term mortality.


BACKGROUND
Cardiogenic shock is the most common cause of death in patients admitted to the coronary care unit. Although studies have reported lower mortality rates in shock treated with angioplasty, few studies have described a cohort of patients with shock who were not selected because they were most likely to benefit from reperfusion therapy.


METHODS
A consecutive series of 200 patients admitted with acute myocardial infarction complicated by cardiogenic shock were studied.


RESULTS
The in-hospital mortality rate was 53%. Variables with significant univariable association with in-hospital death included patency of the infarct-related artery, patient age, lowest cardiac index, highest arteriovenous oxygen difference and left main coronary artery disease. The most important independent predictors of in-hospital death were patency of the infarct-related artery, cardiac index and peak creatine kinase, MB fraction. The mortality rate in patients with patent infarct-related arteries was 33% versus 75% in those with closed arteries and 84% in those in whom arterial patency was unknown. Patients who survived to hospital discharge were followed up for a median of 2 years, with a mortality rate of 18% after 1 year. The best descriptors of the relation between these variables and postdischarge mortality included age, peak creatine kinase, ejection fraction and patency of the infarct-related artery.


CONCLUSIONS
In a large consecutive series of patients with cardiogenic shock with complete follow-up, patency of the infarct-related artery was most strongly associated with in-hospital and long-term mortality. This finding supports an aggressive interventional strategy in patients with cardiogenic shock.
Bengtson
J R
JR
Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710.
Kaplan
A J
AJ
Pieper
K S
KS
Wildermann
N M
NM
Mark
D B
DB
Pryor
D B
DB
Phillips
H R
HR
Califf
R M
RM
D000046:Academic Medical Centers; D000367:Age Factors; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000592:standards; D006328:Cardiac Catheterization; D002302:Cardiac Output; D002316:Cardiotonic Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D017023:Coronary Angiography; D003402:Creatine Kinase / Q000097:blood; D003663:Decision Trees; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D007423:Intra-Aortic Balloon Pumping / Q000592:standards; D007527:Isoenzymes; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000175:diagnosis; D015425:Myocardial Reperfusion / Q000379:methods / Q000592:standards*; D009657:North Carolina / Q000453:epidemiology; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012770:Shock, Cardiogenic / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D013318:Stroke Volume; D016019:Survival Analysis; D015912:Thrombolytic Therapy / Q000592:standards; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D002316:Cardiotonic Agents; D007527:Isoenzymes; D014662:Vasoconstrictor Agents; D003402:Creatine Kinase