Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK?
OBJECTIVE
We sought to determine the outcomes of patients with cardiogenic shock (CS) complicating non-ST-segment elevation acute myocardial infarction (MI).


BACKGROUND
Such patients represent a high-risk (ST-segment depression) or low-risk (normal or nonspecific electrocardiographic findings) group for whom optimal therapy, particularly in the setting of shock, is unknown.


METHODS
We assessed characteristics and outcomes of 881 patients with CS due to predominant left ventricular (LV) dysfunction in the SHOCK Trial Registry.


RESULTS
Patients with non-ST-segment elevation MI (n = 152) were significantly older and had significantly more prior MI, heart failure, azotemia, bypass surgery, and peripheral vascular disease than patients with ST-elevation MI (n = 729). On average, the groups had similar in-hospital LV ejection fractions (approximately 30%), but patients with non-ST-elevation MI had a lower highest creatine kinase and were more likely to have triple-vessel disease. Among patients selected for coronary angiography, the left circumflex artery was the culprit vessel in 34.6% of non-ST-elevation versus 13.4% of ST-elevation MI patients (p = 0.001). Despite having more recurrent ischemia (25.7% vs. 17.4%, p = 0.058), non-ST-elevation patients underwent angiography less often (52.6% vs. 64.1%, p = 0.010). The proportion undergoing revascularization was similar (36.8% for non-ST-elevation vs. 41.9% ST-elevation MI, p = 0.277). In-hospital mortality also was similar in the two groups (62.5% for non-ST-elevation vs. 60.4% ST-elevation MI). After adjustment, ST-segment elevation MI did not independently predict in-hospital mortality (odds ratio, 1.30; 95% confidence interval, 0.83 to 2.02; p = 0.252).


CONCLUSIONS
Patients with CS and non-ST-segment elevation MI have a higher-risk profile than shock patients with ST-segment elevation, but similar in-hospital mortality. More recurrent ischemia and less angiography represent opportunities for earlier intervention, and early reperfusion therapy for circumflex artery occlusion should be considered when non-ST-elevation MI causes CS.
Jacobs
A K
AK
Department of Medicine, Boston Medical Center, Massachusetts 02118, USA. alice.jacobs@bmc.org
French
J K
JK
Col
J
J
Sleeper
L A
LA
Slater
J N
JN
Carnendran
L
L
Boland
J
J
Jiang
X
X
LeJemtel
T
T
Hochman
J S
JS
D000368:Aged; D006328:Cardiac Catheterization; D017023:Coronary Angiography; D004562:Electrocardiography; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007423:Intra-Aortic Balloon Pumping; D008297:Male; D009203:Myocardial Infarction / Q000150:complications / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy; D009204:Myocardial Revascularization; D011446:Prospective Studies; D012042:Registries; D012770:Shock, Cardiogenic / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology* / Q000628:therapy; D015912:Thrombolytic Therapy