Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction.
OBJECTIVE
This study characterized clinical factors predictive of cardiogenic shock developing after thrombolytic therapy for acute myocardial infarction (AMI).


BACKGROUND
Cardiogenic shock remains a common and ominous complication of AMI. By identifying patients at risk of developing shock, preventive measures may be implemented to avert its development.


METHODS
We analyzed baseline variables associated with the development of shock after thrombolytic therapy in the Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. Using a Cox proportional hazards model, we devised a scoring system predicting the risk of shock. This model was then validated in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III) cohort.


RESULTS
Shock developed in 1,889 patients a median of 11.6 h after enrollment. The major factors associated with increased adjusted risk of shock were age (chi2 = 285, hazard ratio [95% confidence interval] 1.47 [1.40, 1.53]), systolic blood pressure (chi2 = 280), heart rate (chi2 = 225) and Killip class (chi2 = 161, hazard ratio 1.70 [1.52, 1.90] and 2.95 [2.39, 3.63] for Killip II versus I and Killip III versus I, respectively) upon presentation. Together, these four variables accounted for >85% of the predictive information. These findings were transformed into an algorithm with a validated concordance index of 0.758. Applied to the GUSTO-III cohort, the four variables accounted for > 95% of the predictive information, and the validated concordance index was 0.796.


CONCLUSIONS
A scoring system accurately predicts the risk of shock after thrombolytic therapy for AMI based primarily on the patient's age and physical examination on presentation.
Hasdai
D
D
Rabin Medical Center, Petah Tikva, Israel.
Califf
R M
RM
Thompson
T D
TD
Hochman
J S
JS
Ohman
E M
EM
Pfisterer
M
M
Bates
E R
ER
Vahanian
A
A
Armstrong
P W
PW
Criger
D A
DA
Topol
E J
EJ
Holmes
D R
DR
D000368:Aged; D000465:Algorithms; D004359:Drug Therapy, Combination; D005260:Female; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy*; D011379:Prognosis; D016016:Proportional Hazards Models; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000209:etiology* / Q000517:prevention & control; D013300:Streptokinase / Q000008:administration & dosage* / Q000009:adverse effects; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects
D006493:Heparin; D013300:Streptokinase; D010959:Tissue Plasminogen Activator