Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction.
BACKGROUND
Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction (MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking.


OBJECTIVE
To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI.


METHODS
The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock (mean [SD] age at randomization, 66 [11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years (median for survivors, 6 years).


METHODS
All-cause mortality during long-term follow-up.


RESULTS
The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years (13.1% and 13.2%, respectively; hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.57-0.97; log-rank P = .03). At 6 years, overall survival rates were 32.8% and 19.6% in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed (HR, 0.59; 95% CI, 0.36-0.95; P = .03). The 6-year survival rates for the hospital survivors were 62.4% vs 44.4% for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3% vs 14.3% and, for the 1-year survivors, 8.0% vs 10.7%. There was no significant interaction between any subgroup and treatment effect.


CONCLUSIONS
In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2% absolute and a 67% relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.


BACKGROUND
clinicaltrials.gov Identifier: NCT00000552.
Hochman
Judith S
JS
Cardiovascular Clinical Research Center, New York University School of Medicine, New York 10016, USA. judith.hochman@med.nyu.edu
Sleeper
Lynn A
LA
Webb
John G
JG
Dzavik
Vladimir
V
Buller
Christopher E
CE
Aylward
Philip
P
Col
Jacques
J
White
Harvey D
HD
D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D001026:Coronary Artery Bypass; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction; D009204:Myocardial Revascularization; D012770:Shock, Cardiogenic / Q000401:mortality / Q000628:therapy*; D016019:Survival Analysis; D017741:Survivors; D015912:Thrombolytic Therapy