title: Outcomes with invasive vs conservative management of cardiogenic shock complicating acute myocardial infarction.
abstract: BACKGROUND
  In the SHOCK trial, an invasive strategy of early revascularization was associated with a significant mortality benefit at 6 months when compared with initial stabilization in patients with cardiogenic shock complicating acute myocardial infarction. Our objectives were to evaluate the data on real-world practice and outcomes of invasive vs conservative management in patients with cardiogenic shock.
  
  
  METHODS
  We analyzed data from the Nationwide Inpatient Sample from 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery) vs conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality.
  
  
  RESULTS
  We identified 60,833 patients with cardiogenic shock, of which 20,644 patients (10,322 in each group) with similar propensity scores, including 11,004 elderly patients (≥75 years), were in the final analysis. Patients who underwent invasive management had 59% lower odds of in-hospital mortality (37.7% vs 59.7%; odds ratio [OR] 0.41; 95% confidence interval [CI], 0.39-0.43; P < .0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (≥75 years) (44.0% vs 63.6%; OR 0.45; 95% CI, 0.42-0.49; P < .0001) and those younger than 75 years (30.6% vs 55.1%; OR 0.36; 95% CI, 0.33-0.39; P < .0001), although the magnitude of risk reduction differed (Pinteraction < .0001).
  
  
  CONCLUSIONS
  In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup.
authors.affiliation: New York University School of Medicine, New York. Electronic address: sripalbangalore@gmail.com.
authors.forename: Sripal
authors.initials: S
authors.lastname: Bangalore
authors.affiliation: Medical College of Wisconsin, Milwaukee.
authors.forename: Navdeep
authors.initials: N
authors.lastname: Gupta
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Yu
authors.initials: Y
authors.lastname: Guo
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Anuradha
authors.initials: A
authors.lastname: Lala
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Leora
authors.initials: L
authors.lastname: Balsam
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Robert O
authors.initials: RO
authors.lastname: Roswell
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Alex
authors.initials: A
authors.lastname: Reyentovich
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Judith S
authors.initials: JS
authors.lastname: Hochman
mesh_terms: D000368:Aged; D006328:Cardiac Catheterization; D001026:Coronary Artery Bypass; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000628:therapy; D062645:Percutaneous Coronary Intervention; D012770:Shock, Cardiogenic / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D016896:Treatment Outcome
keywords: Cardiogenic; Conservative; Invasive; Shock