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CLINICAL STUDIES

Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction

David Hasdai, MD^*, Robert M. Califf, MD, FACC, Trevor D. Thompson, BS, Judith S. Hochman, MD, FACC, E. Magnus Ohman, MD, FACC, Matthias Pfisterer, MD, FACC, Eric R. Bates, MD, FACC^||, Alec Vahanian, MD^¶, Paul W. Armstrong, MD, FACC^#, Douglas A. Criger, MPH, Eric J. Topol, MD, FACC^** and David R. Holmes, Jr., MD, FACC

^* Rabin Medical Center, Petah Tikva, Israel
Duke University Medical Center, Durham, North Carolina, USA
St. Luke’s/Roosevelt Hospital Center, New York, New York, USA
University Hospital Basel, Basel, Switzerland
^|| University of Michigan Medical Center, Ann Arbor, Michigan, USA
^¶ Hospital Tenon, Paris, France
^# University of Alberta, Walter C. Mackenzie Health Center, Edmonton, Canada
^** The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Mayo Clinic, Rochester, Minnesota, USA

Manuscript received March 9, 1999; revised manuscript received July 2, 1999, accepted September 21, 1999.

Reprint requests and correspondence: Dr. David R. Holmes Jr, Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905

OBJECTIVES

This study characterized clinical factors predictive of cardiogenic shock developing after thrombolytic therapy for acute myocardial infarction (AMI).

BACKGROUND

Cardiogenic shock remains a common and ominous complication of AMI. By identifying patients at risk of developing shock, preventive measures may be implemented to avert its development.

METHODS

We analyzed baseline variables associated with the development of shock after thrombolytic therapy in the Global Utilization of Streptikonase and Tissue-Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. Using a Cox proportional hazards model, we devised a scoring system predicting the risk of shock. This model was then validated in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III) cohort.

RESULTS

Shock developed in 1,889 patients a median of 11.6 h after enrollment. The major factors associated with increased adjusted risk of shock were age (² = 285, hazard ratio [95% confidence interval] 1.47 [1.40, 1.53]), systolic blood pressure (² = 280), heart rate (² = 225) and Killip class (² = 161, hazard ratio 1.70 [1.52, 1.90] and 2.95 [2.39, 3.63] for Killip II versus I and Killip III versus I, respectively) upon presentation. Together, these four variables accounted for >85% of the predictive information. These findings were transformed into an algorithm with a validated concordance index of 0.758. Applied to the GUSTO-III cohort, the four variables accounted for >95% of the predictive information, and the validated concordance index was 0.796.

CONCLUSIONS

A scoring system accurately predicts the risk of shock after thrombolytic therapy for AMI based primarily on the patient’s age and physical examination on presentation.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CI = confidence interval   ECG = electrocardiographic   GUSTO-I = Global Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries   GUSTO-III = Global Use of Strategies to Open Occluded Coronary Arteries

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