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Volume 341:625-634 August 26, 1999 Number 9 Next

	Full Text PDF Editorial by Ryan, T. J. Letters Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background The leading cause of death in patients hospitalized for acute myocardial infarction is cardiogenic shock. We conducted a randomized trial to evaluate early revascularization in patients with cardiogenic shock.

Methods Patients with shock due to left ventricular failure complicating myocardial infarction were randomly assigned to emergency revascularization (152 patients) or initial medical stabilization (150 patients). Revascularization was accomplished by either coronary-artery bypass grafting or angioplasty. Intraaortic balloon counterpulsation was performed in 86 percent of the patients in both groups. The primary end point was mortality from all causes at 30 days. Six-month survival was a secondary end point.

Results The mean (±SD) age of the patients was 66±10 years, 32 percent were women, and 55 percent had been transferred from other hospitals. The median time to the onset of shock was 5.6 hours after infarction, and most infarcts were anterior in location. Ninety-seven percent of the patients assigned to revascularization underwent early coronary angiography, and 87 percent underwent revascularization; only 2.7 percent of the patients assigned to medical therapy crossed over to early revascularization without clinical indication. Overall mortality at 30 days did not differ significantly between the revascularization and medical-therapy groups (46.7 percent and 56.0 percent, respectively; difference, –9.3 percent; 95 percent confidence interval for the difference, –20.5 to 1.9 percent; P=0.11). Six-month mortality was lower in the revascularization group than in the medical-therapy group (50.3 percent vs. 63.1 percent, P=0.027).

Conclusions In patients with cardiogenic shock, emergency revascularization did not significantly reduce overall mortality at 30 days. However, after six months there was a significant survival benefit. Early revascularization should be strongly considered for patients with acute myocardial infarction complicated by cardiogenic shock.

Source Information

From St. Luke's–Roosevelt Hospital Center and Columbia University, New York (J.S.H., J.N.S.); New England Research Institutes, Watertown, Mass. (L.A.S., S.M.M.); St. Paul's Hospital, Vancouver, B.C., Canada (J.G.W.); New York Hospital–Cornell Medical Center, New York (T.A.S.); Green Lane Hospital, Auckland, New Zealand (H.D.W.); the University of Arkansas, Little Rock (J.D.T); Vancouver General Hospital, Vancouver, B.C., Canada (C.E.B.); Boston Medical Center, Boston (A.K.J.); Cliniques Universitaires St. Luc, Brussels, Belgium (J.C.); and Albert Einstein College of Medicine, Bronx, N.Y. (T.H.L.). Other authors were Michael H. Picard, M.D., Massachusetts General Hospital, Boston; Mark A. Menegus, M.D., Montefiore Medical Center–Albert Einstein College of Medicine, Bronx, N.Y.; Jean Boland, M.D., Centre Hospitalier Régional Citadelle, Liege, Belgium; Vladimir Dzavik, M.D., University of Alberta Hospital, Edmonton, Alta., Canada; Christopher R. Thompson, M.D., C.M., St. Paul's Hospital, Vancouver, B.C., Canada; S. Chiu Wong, M.D., New York Hospital Medical Center of Queens, Flushing, N.Y.; Richard Steingart, M.D., Winthrop University Hospital, Mineola, N.Y.; Robert Forman, M.D., Albert Einstein College of Medicine, Bronx, N.Y.; Philip E. Aylward, B.M., B.Ch., Ph.D., Flinders Medical Centre, Adelaide, S.A., Australia; Emilie Godfrey, M.S., R.D., St. Luke's–Roosevelt Hospital Center, New York; and Patrice Desvigne-Nickens, M.D., National Heart, Lung, and Blood Institute, Bethesda, Md.Preliminary data were presented at the American College of Cardiology meeting, New Orleans, March 7–10, 1999.

Address reprint requests to Dr. Hochman at St. Luke's–Roosevelt Hospital Center, 1111 Amsterdam Ave., New York, NY 10025.

Full Text of this Article

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