title: Interhospital transfer for early revascularization in patients with ST-elevation myocardial infarction complicated by cardiogenic shock--a report from the SHould we revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) trial and registry.
abstract: BACKGROUND
  Early revascularization (ERV) in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS) reduces mortality rates. Patients admitted to hospitals without revascularization capability have high mortality rates and are not often transferred for ERV.
  
  
  METHODS
  Transfer and direct-admit patients with STEMI from the SHOCK Trial and Registry with left ventricular failure (N = 969) were analyzed to determine benefit of ERV in transfer patients.
  
  
  RESULTS
  Transfer patients (46%) were younger and less likely to have prior hypertension, myocardial infarction, and heart failure. They received more aggressive treatment, were revascularized later after CS (median 7.3 vs 3.9 hours, P = .0002), and had similar adjusted inhospital mortality compared with direct-admit patients (55% vs 56%). Inhospital mortality was lower in ERV than no/late revascularization (41% vs 53%, P = .017 for transfer patients; 55% vs 71%, P = .0003 for direct-admit patients). Multiple logistic regression showed that inhospital mortality was associated with age (odds ratio [OR] 1.50 per decade increase, 95% CI 1.31-1.73, P < .0001), mean arterial pressure (OR 0.98 per 1 mm Hg increase, 95% CI 0.97-0.99, P < .0001), fibrinolysis before CS (OR 0.65, 95% CI 0.52-0.96, P = .040), and ERV (OR 0.70, 95% CI 0.52-0.96, P = .028), but not transfer admission (OR 1.23, 95% CI 0.86-1.74, P = .26).
  
  
  CONCLUSIONS
  Despite longer time to treatment, transfer patients are a selected population with similar adjusted inhospital mortality and ERV benefit as direct-admit patients. Selected patients with STEMI and CS admitted to hospitals without revascularization capability should be transferred to centers with revascularization capability for immediate angiography.
authors.affiliation: Cardiovascular Clinical Research Center, New York University School of Medicine, New York, NY, USA. rjeger@uhbs.ch
authors.forename: Raban V
authors.initials: RV
authors.lastname: Jeger
authors.forename: Chi-Hong
authors.initials: CH
authors.lastname: Tseng
authors.forename: Judith S
authors.initials: JS
authors.lastname: Hochman
authors.forename: Eric R
authors.initials: ER
authors.lastname: Bates
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003327:Coronary Disease / Q000601:surgery; D015908:Counterpulsation; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis*; D009204:Myocardial Revascularization; D010343:Patient Admission; D010360:Patient Transfer; D016032:Randomized Controlled Trials as Topic; D012042:Registries; D012770:Shock, Cardiogenic / Q000209:etiology* / Q000601:surgery* / Q000628:therapy; D015912:Thrombolytic Therapy; D013997:Time Factors