Author + information
- Received January 18, 2003
- Revision received March 20, 2003
- Accepted March 27, 2003
- Published online October 15, 2003.
- John G Webb, MD, FACC*,* (, )
- April M Lowe, MS†,
- Timothy A Sanborn, MD, FACC‡,
- Harvey D White, DSc§,
- Lynn A Sleeper, ScD†,
- Ronald G Carere, MD, FACC*,
- Christopher E Buller, MD, FACC∥,
- S.Chiu Wong, MD, FACC¶,
- Jean Boland, MD#,
- Vlad Dzavik, MD**,
- Mark Porway, MD, FACC††,
- Gordon Pate, MB*,
- Geoffrey Bergman, MD, FACC¶,
- Judith S Hochman, MD, FACC‡‡,
- for the SHOCK Investigators
- ↵*Reprint requests and correspondence:
Dr. John G. Webb, Director, Cardiac Catheterization and Interventional Cardiology, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6.
Objectives 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.
☆ Supported by R01 grants HL50020, HL49970, 1994 to 1999, from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
- Received January 18, 2003.
- Revision received March 20, 2003.
- Accepted March 27, 2003.
- American College of Cardiology Foundation