Myocardial infarction: cardiogenic shock: early revascularisation reduced mortality

Clinical bottom line (level 1b)

  1. Patients with cardiogenic shock following a myocardial infarction who received early revascularisation compared with initial medical stabilisation and delayed revascularisation were less likely to die (NNT = 7 at 12 months) .
Hochman et al: JAMA 2001; 285 : 190-192
Expires January 2004

The study

Double-blinded ?concealed randomised trial with intention-to-treat
Setting: 36 acute hospitals with angioplasty and cardiac surgery facilities, Europe, the Americas, Australiasia

302 patients (aged mean 66, 68% male) with an acute myocardial infarction who developed cardiogenic shock due to LV failure within 36 hours (defined as hypotension with end-organ perfusion, cardiac index 2.2 l/min per m2 body surface area or less, and pulmonary wedge pressure 15 mmHg or more)

Excluded if
  • unsuitability for revascularisation
  • severe systemic illness
  • severe valvular heart disease
  • dilated cardiomyopathy
  • no evidence of Q waves, posterior infarction or new left-bundle branch block on ECG

Control Group: (n = 150, 149 analysed): initial medical stabilisation: thrombolysis, intra-aortic balloon counterpulsation and subsequent revascularisation with PTCA or CABG at least 54 hours after randomisation.
Experimental Group: (n = 152, 152 analysed): early revascularisation with either PTCA or CABG within 6 hours

99% followed for 12 months

The evidence

Outcome Time to outcome CER EER RRR
(95% CI)		 ARR
(95% CI)		 NNT
(95% CI)
death 12 months 100
(66.7%)		 81
(53.3%)		 20%
(4% to 34%)		 13.4%
(2.43% to 24.3%)		 7
(4 to 41)

Citation

  1. Hochman JS, Sleeper LA, White HD, et al: one-year survival following early revascularisation for cardiogenic shock (SHOCK). JAMA 2001; 285 : 190-192
Search Terms: from ACP Journal Club
Contributor: Chris Ball, January 2002
Reviewer:

Clinical Question.
Patient myocardial infarction, cardiogenic shock
Intervention or Exposure early revascularisation
Comparison initial medical stabilisation followed by delayed revascularisation
Outcome death