Contemporary reperfusion therapy for cardiogenic shock: the GUSTO-I trial experience. The GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries

Cardiac Care Unit, Mayo Clinic, Rochester, Minnesota 55905, USA.

OBJECTIVES. This study sought to examine the incidence, temporal profile and clinical implications of shock in a large trial of thrombolytic therapy for acute myocardial infarction. BACKGROUND. Despite advances in the treatment of acute ischemic syndromes, cardiogenic shock remains associated with significant morbidity and mortality. METHODS. Patients who presented within 6 h of symptom onset were randomized to four treatment strategies: 1) streptokinase plus subcutaneous heparin; 2) streptokinase plus intravenous heparin; 3) accelerated recombinant tissue-type plasminogen activator (rt-PA) plus intravenous heparin; or 4) streptokinase and rt-PA plus intravenous heparin. The primary end point was 30-day all-cause mortality. RESULTS. Shock occurred in 2,972 patients (7.2%): 315 (11%) had shock on arrival, and 2,657 (89%) developed shock after hospital admission. Reinfarction occurred in 11% of patients who developed shock compared with 3% of patients without shock. The mortality rate was significantly higher in patients who presented with (57%) or developed (55%) shock than in those without shock (3%) (p < 0.001). Shock developed significantly less frequently in patients receiving rt-PA. There were fewer deaths in patients who presented with shock and were treated with streptokinase plus intravenous heparin or who developed shock and were treated with streptokinase plus subcutaneous heparin. Patients who developed shock had a significantly lower 30-day mortality rate if angioplasty was performed. CONCLUSIONS. Because cardiogenic shock occurred most often after admission and with recurrent ischemia and reinfarction, recognizing signs of incipient shock may improve outcome. Fewer patients treated with rt-PA developed shock, yet those developing shock had the same high mortality rate as those presenting with shock, regardless of treatment. Only angioplasty was associated with a significantly lower mortality rate.

This article has been cited by other articles:

				D. R. Holmes Jr Reply J. Am. Coll. Cardiol., July 22, 2008; 52(4): 316 - 316. [Full Text] [PDF]

				M. Kooshkabadi, A. Kalogeropoulos, V. C. Babaliaros, and S. Lerakis Transesophageal guided left atrial positioning of a percutaneous ventricular assist device Eur J Echocardiogr, January 1, 2008; 9(1): 175 - 177. [Abstract] [Full Text] [PDF]

				H. Thiele, R. W. Smalling, and G. C. Schuler Percutaneous left ventricular assist devices in acute myocardial infarction complicated by cardiogenic shock Eur. Heart J., September 1, 2007; 28(17): 2057 - 2063. [Abstract] [Full Text] [PDF]

				R. F Potthoff, G. E Tudor, K. S Pieper, and V. Hasselblad Can one assess whether missing data are missing at random in medical studies? Statistical Methods in Medical Research, June 1, 2006; 15(3): 213 - 234. [Abstract] [PDF]

				R. V. Jeger, S. M. Harkness, K. Ramanathan, C. E. Buller, M. E. Pfisterer, L. A. Sleeper, J. S. Hochman, and for the SHOCK Investigators Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry Eur. Heart J., March 2, 2006; 27(6): 664 - 670. [Abstract] [Full Text] [PDF]

				Part 8: Stabilization of the Patient With Acute Coronary Syndromes Circulation, December 13, 2005; 112(24_suppl): IV-89 - IV-110. [Full Text] [PDF]

				A. Migliorini and D. Antoniucci Patient selection bias in primary percutaneous coronary intervention trials: a critical issue Eur. Heart J. Suppl., October 1, 2005; 7(suppl_I): I21 - I26. [Abstract] [Full Text] [PDF]

				H. D. White, S. F. Assmann, T. A. Sanborn, A. K. Jacobs, J. G. Webb, L. A. Sleeper, C.-K. Wong, J. T. Stewart, P. E.G. Aylward, S.-C. Wong, et al. Comparison of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting After Acute Myocardial Infarction Complicated by Cardiogenic Shock: Results From the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) Trial Circulation, September 27, 2005; 112(13): 1992 - 2001. [Abstract] [Full Text] [PDF]

				C. S. Duvernoy and E. R. Bates Management of Cardiogenic Shock Attributable to Acute Myocardial Infarction in the Reperfusion Era J Intensive Care Med, July 1, 2005; 20(4): 188 - 198. [Abstract] [PDF]

				K. P. Bouki, G. Pavlakis, and E. Papasteriadis Management of Cardiogenic Shock Due to Acute Coronary Syndromes Angiology, March 1, 2005; 56(2): 123 - 130. [Abstract] [PDF]

				A G C Sutton, P Finn, J A Hall, A A Harcombe, R A Wright, and M A de Belder Predictors of outcome after percutaneous treatment for cardiogenic shock Heart, March 1, 2005; 91(3): 339 - 344. [Abstract] [Full Text] [PDF]

				G Montalescot, H R Andersen, D Antoniucci, A Betriu, M J de Boer, L Grip, F J Neumann, and M T Rothman Recommendations on percutaneous coronary intervention for the reperfusion of acute ST elevation myocardial infarction Heart, June 1, 2004; 90(6): e37 - e37. [Abstract] [Full Text] [PDF]

				N. Lim, M.-J. Dubois, D. De Backer, and J.-L. Vincent Do All Nonsurvivors of Cardiogenic Shock Die With a Low Cardiac Index? Chest, November 1, 2003; 124(5): 1885 - 1891. [Abstract] [Full Text] [PDF]

				M. B. Vroom Epidemiology and Pharmacotherapy of Acute Heart Failure Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2003; 7(1): 3 - 12. [PDF]

				D.R Holmes The final common pathway Eur. Heart J., February 1, 2003; 24(3): 214 - 216. [Full Text] [PDF]

				M.G Lindholm, L Kober, S Boesgaard, C Torp-Pedersen, J Aldershvile, and on behalf of the TRACE study group Cardiogenic shock complicating acute myocardial infarction: Prognostic impact of early and late shock development Eur. Heart J., February 1, 2003; 24(3): 258 - 265. [Abstract] [Full Text] [PDF]

				V. Menon and J. S Hochman MANAGEMENT OF CARDIOGENIC SHOCK COMPLICATING ACUTE MYOCARDIAL INFARCTION Heart, December 1, 2002; 88(5): 531 - 537. [Full Text] [PDF]

				H. Thiele, B. Lauer, R. Hambrecht, E. Boudriot, H. A. Cohen, and G. Schuler Reversal of Cardiogenic Shock by Percutaneous Left Atrial-to-Femoral Arterial Bypass Assistance Circulation, December 11, 2001; 104(24): 2917 - 2922. [Abstract] [Full Text] [PDF]

				L Carnendran, R Abboud, L.A Sleeper, R Gurunathan, J.G Webb, V Menon, V Dzavik, T Cocke, J.S Hochman, and for the SHOCK Investigators Trends in cardiogenic shock: report from the SHOCK Study Eur. Heart J., March 2, 2001; 22(6): 472 - 478. [Abstract] [PDF]

				J. A. Magovern, M. J. Sussman, A. H. Goldstein, G. W. Szydlowski, E. B. Savage, and S. Westaby Clinical results with the AB-180 left ventricular assist device Ann. Thorac. Surg., March 1, 2001; 71 (2007): S121 - S124. [Abstract] [Full Text] [PDF]

				C.H. Davies Revascularization for cardiogenic shock QJM, February 1, 2001; 94(2): 57 - 67. [Full Text] [PDF]

				L. W. Stevenson and R. L. Kormos Mechanical cardiac support 2000: current applications and future trial design: June 15-16, 2000 Bethesda, Maryland J. Am. Coll. Cardiol., January 1, 2001; 37(1): 340 - 370. [Full Text] [PDF]

				V Menon, J.S Hochman, A Stebbins, M Pfisterer, J Col, R.D Anderson, D Hasdai, D.R Holmes Jr, E.R Bates, E.J Topol, et al. Lack of progress in cardiogenic shock: lessons from the GUSTO trials Eur. Heart J., December 1, 2000; 21(23): 1928 - 1936. [Abstract] [PDF]

				J. S. Hochman, C. E. Buller, L. A. Sleeper, J. Boland, V. Dzavik, T. A. Sanborn, E. Godfrey, H. D. White, J. Lim, T. LeJemtel, et al. Cardiogenic shock complicating acute myocardial infarction--etiologies, management and outcome: a report from the SHOCK Trial Registry J. Am. Coll. Cardiol., September 1, 2000; 36(3_Suppl_A): 1063 - 1070. [Abstract] [Full Text] [PDF]

				S. C. Wong, T. Sanborn, L. A. Sleeper, J. G. Webb, R. Pilchik, D. Hart, S. Mejnartowicz, T. A. Antonelli, R. Lange, J. K. French, et al. Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry J. Am. Coll. Cardiol., September 1, 2000; 36(3_Suppl_A): 1077 - 1083. [Abstract] [Full Text] [PDF]

				J. G. Webb, L. A. Sleeper, C. E. Buller, J. Boland, A. Palazzo, E. Buller, H. D. White, J. S. Hochman, and for the SHOCK Investigators Implications of the timing of onset of cardiogenic shock after acute myocardial infarction: a report from the SHOCK Trial Registry J. Am. Coll. Cardiol., September 1, 2000; 36(3_Suppl_A): 1084 - 1090. [Abstract] [Full Text] [PDF]

				D. M. Shindler, S. T. Palmeri, T. A. Antonelli, L. A. Sleeper, J. Boland, T. P. Cocke, J. S. Hochman, and for the SHOCK Investigators Diabetes mellitus in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry J. Am. Coll. Cardiol., September 1, 2000; 36(3_Suppl_A): 1097 - 1103. [Abstract] [Full Text] [PDF]

				Trial of Abciximab With and Without Low-Dose Reteplase for Acute Myocardial Infarction Circulation, June 20, 2000; 101(24): 2788 - 2794. [Abstract] [Full Text] [PDF]

				S G Williams, D J Wright, and L B Tan Management of cardiogenic shock complicating acute myocardial infarction: towards evidence based medical practice Heart, June 1, 2000; 83(6): 621 - 626. [Full Text]

				D. R. Thiemann, J. Coresh, S. P. Schulman, G. Gerstenblith, W. J. Oetgen, and N. R. Powe Lack of Benefit for Intravenous Thrombolysis in Patients With Myocardial Infarction Who Are Older Than 75 Years Circulation, May 16, 2000; 101(19): 2239 - 2246. [Abstract] [Full Text] [PDF]

				D. Hasdai, R. M. Califf, T. D. Thompson, J. S. Hochman, E. M. Ohman, M. Pfisterer, E. R. Bates, A. Vahanian, P. W. Armstrong, D. A. Criger, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction J. Am. Coll. Cardiol., January 1, 2000; 35(1): 136 - 143. [Abstract] [Full Text] [PDF]

				D. R. Holmes Jr, P. B. Berger, J. S. Hochman, C. B. Granger, T. D. Thompson, R. M. Califf, A. Vahanian, E. R. Bates, and E. J. Topol Cardiogenic Shock in Patients With Acute Ischemic Syndromes With and Without ST-Segment Elevation Circulation, November 16, 1999; 100(20): 2067 - 2073. [Abstract] [Full Text] [PDF]

				J. S. Hochman, L. A. Sleeper, J. G. Webb, T. A. Sanborn, H. D. White, J. D. Talley, C. E. Buller, A. K. Jacobs, J. N. Slater, J. Col, et al. Early Revascularization in Acute Myocardial Infarction Complicated by Cardiogenic Shock N. Engl. J. Med., August 26, 1999; 341(9): 625 - 634. [Abstract] [Full Text] [PDF]

				R. J. Goldberg, N. A. Samad, J. Yarzebski, J. Gurwitz, C. Bigelow, and J. M. Gore Temporal Trends in Cardiogenic Shock Complicating Acute Myocardial Infarction N. Engl. J. Med., April 15, 1999; 340(15): 1162 - 1168. [Abstract] [Full Text] [PDF]

				T. P. Wharton Jr., N. S. McNamara, F. A. Fedele, M. I. Jacobs, A. R. Gladstone, and E. J. Funk Primary angioplasty for the treatment of acute myocardial infarction: experience at two community hospitals without cardiac surgery J. Am. Coll. Cardiol., April 1, 1999; 33(5): 1257 - 1265. [Abstract] [Full Text] [PDF]

				P. B. Berger, R. H. Tuttle, D. R. Holmes Jr, E. J. Topol, P. E. Aylward, J. H. Horgan, and R. M. Califf One-Year Survival Among Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock, and its Relation to Early Revascularization : Results From the GUSTO-I Trial Circulation, February 23, 1999; 99(7): 873 - 878. [Abstract] [Full Text] [PDF]

				R. LIM, M. I WALTERS, and M. S NORELL Transferring patients for primary infarct angioplasty Heart, October 1, 1997; 78(4): 325 - 326. [Full Text] [PDF]

				P. B. Berger, D. R. Holmes Jr, A. L. Stebbins, E. R. Bates, R. M. Califf, and E. J. Topol Impact of an Aggressive Invasive Catheterization and Revascularization Strategy on Mortality in Patients With Cardiogenic Shock in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) Trial : An Observational Study Circulation, July 1, 1997; 96(1): 122 - 127. [Abstract] [Full Text]

				E. D. Peterson, L. J. Shaw, and R. M. Califf Clinical Guideline: Part II: Risk Stratification after Myocardial Infarction Ann Intern Med, April 1, 1997; 126(7): 561 - 582. [Abstract] [Full Text]

				E. M. Ohman, P. W. Armstrong, R. H. Christenson, C. B. Granger, H. A. Katus, C. W. Hamm, M. A. O'Hanesian, G. S. Wagner, N. S. Kleiman, F. E. Harrell, et al. Cardiac Troponin T Levels for Risk Stratification in Acute Myocardial Ischemia N. Engl. J. Med., October 31, 1996; 335(18): 1333 - 1342. [Abstract] [Full Text] [PDF]

				L. Pilote, D. P. Miller, R. M. Califf, J. S. Rao, W. D. Weaver, and E. J. Topol Determinants of the Use of Coronary Angiography and Revascularization after Thrombolysis for Acute Myocardial Infarction N. Engl. J. Med., October 17, 1996; 335(16): 1198 - 1205. [Abstract] [Full Text] [PDF]

				MI, Reperfusion, and Cardiac Shock Journal Watch Cardiology, November 1, 1995; 1995(1101): 10 - 10. [Full Text]