Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial.
OBJECTIVE
We examined the clinical, angiographic, and procedural characteristics determining survival after percutaneous coronary intervention (PCI) for cardiogenic shock.


BACKGROUND
The SHOCK (SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK?) trial prospectively enrolled patients with shock complicating acute myocardial infarction (MI). Patients were randomized to a strategy of early revascularization or initial medical stabilization.


METHODS
Patients randomized to early revascularization underwent PCI or bypass surgery on the basis of predefined clinical criteria. Patients randomized to early revascularization who underwent PCI and had angiographic films available for analysis are the subject of this report (n = 82).


RESULTS
The median time from MI to PCI was 11 h. The majority of patients had occluded culprit arteries (Thrombolysis In Myocardial Infarction [TIMI] grade 0 or 1 flow in 62%) and multivessel disease (81%). One-year mortality in PCI patients was 50%. Mortality was 39% if PCI was successful but 85% if unsuccessful (p < 0.001). Mortality was 38% if TIMI flow grade 3 was achieved, 55% with TIMI grade 2 flow, and 100% with TIMI grade 0 or 1 flow (p < 0.001). Mortality was 67% if severe mitral regurgitation was documented. Independent correlates of mortality were as follows: increasing age (p < 0.001), lower systolic blood pressure (p = 0.009), increasing time from randomization to PCI (p = 0.019), lower post-PCI TIMI flow (0/1 vs. 2/3) (p < 0.001), and multivessel PCI (p = 0.040).


CONCLUSIONS
Restoration of coronary blood flow is a major predictor of survival in cardiogenic shock. Benefit appears to extend beyond the generally accepted 12-h post-infarction window. Surgery should be considered in shock patients with severe mitral insufficiency or multivessel disease not amenable to relatively complete percutaneous revascularization.
Webb
John G
JG
St Paul's Hospital, Vancouver, Canada. webb@providencehealth.bc.ca
Lowe
April M
AM
Sanborn
Timothy A
TA
White
Harvey D
HD
Sleeper
Lynn A
LA
Carere
Ronald G
RG
Buller
Christopher E
CE
Wong
S Chiu
SC
Boland
Jean
J
Dzavik
Vlad
V
Porway
Mark
M
Pate
Gordon
G
Bergman
Geoffrey
G
Hochman
Judith S
JS
D000368:Aged; D016022:Case-Control Studies; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D003326:Coronary Circulation; D005260:Female; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000150:complications; D009204:Myocardial Revascularization; D016016:Proportional Hazards Models; D015983:Selection Bias; D012770:Shock, Cardiogenic / Q000000981:diagnostic imaging / Q000401:mortality* / Q000628:therapy*; D015607:Stents; D013997:Time Factors; D018487:Ventricular Dysfunction, Left / Q000628:therapy