CLINICAL STUDY
Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry
S. Chiu Wong, MD, FACC*,
Timothy Sanborn, MD*,
Lynn A. Sleeper, ScD ,
John G. Webb, MD ,
Robert Pilchik, MD ,
David Hart, MD,
Slawomir Mejnartowicz, MD,
Tracy A. Antonelli, MPH,
Richard Lange, MD||,
John K. French, MB, PhD, ChB¶,
Geoffrey Bergman, MD*,
Thierry LeJemtel, MD, FACC**,
Judith S. Hochman, MD, FACC for the SHOCK Investigators
* Department of Internal Medicine (Division of Cardiology), the New York Hospital–Cornell Medical Center, New York, New York, USA
New England Research Institutes, Watertown, Massachusetts, USA
St. Paul’s Hospital, Vancouver, British Columbia, Canada
St. Luke’s–Roosevelt Hospital Center, New York, New York, USA
|| University of Texas–Southwestern Medical Center, Dallas, Texas, USA
¶ Green Lane Hospital, Auckland, New Zealand
** Albert Einstein College of Medicine, Bronx, New York, USA
Manuscript received February 16, 2000;
revised manuscript received June 14, 2000,
accepted June 15, 2000.
Reprint requests and correspondence: Dr. S. Chiu Wong, Director, Cardiac Catheterization Laboratory, New York Presbyterian Hospital, Weill Medical College of Cornell University, Starr Pavilion 4, 520 East 70th Street, New York, New York 10021
scwong{at}med.cornell.edu
Objectives
We sought to delineate the angiographic findings, clinical correlates and in-hospital outcomes in patients with cardiogenic shock (CS) complicating acute myocardial infarction.
Background
Patients with CS complicating acute myocardial infarction carry a grave prognosis. Detailed angiographic findings in a large, prospectively identified cohort of patients with CS are currently lacking.
Methods
We compared the clinical characteristics, angiographic findings, and in-hospital outcomes of 717 patients selected to undergo angiography and 442 not selected, overall and by shock etiology: left or right ventricular failure versus mechanical complications.
Results
Patients who underwent angiography had lower baseline risk and a better hemodynamic profile than those who did not. Overall, 15.5% of the patients had significant left main lesions on angiography, and 53.4% had three-vessel disease, with higher rates of both for those with ventricular failure, compared with patients who had mechanical complications. Among patients who underwent angiography, those with ventricular failure had significantly lower in-hospital mortality than patients with mechanical complications (45.2% vs. 57.0%; p = 0.021). Importantly, for patients with ventricular failure, in-hospital mortality also correlated with disease severity: 35.0% for no or single-vessel disease versus 50.8% for three-vessel disease. Furthermore, mortality was associated with the culprit lesion location (78.6% in left main lesion, 69.7% in saphenous vein graft lesions, 42.4% in circumflex lesions, 42.3% in left anterior descending lesions, and 37.4% in right coronary artery lesions), and Thrombolysis In Myocardial Infarction (TIMI) flow grade (46.5% in TIMI 0/1, 49.4% in TIMI 2 and 26% in TIMI 3).
Conclusions
Patients who underwent angiographic study in the SHOCK Trial Registry had a more benign cardiac risk profile, more favorable hemodynamic findings and lower in-hospital mortality than those for whom angiograms were not obtained. Patients with CS caused by ventricular failure had more severe atherosclerosis, and a different distribution of culprit vessel involvement but lower in-hospital mortality, than those with mechanical complications. Overall in-hospital survival correlates with the extent of coronary artery obstructions, location of culprit lesion and baseline coronary TIMI flow grade.
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Abbreviations and Acronyms
| | AMI | = acute myocardial infarction | | CAD | = coronary artery disease | | CK(-MB) | = creatine phosphokinase (-MB) | | CS | = cardiogenic shock | | IABP | = intra-aortic balloon pump | | LAD | = left anterior descending | | LV | = left ventricular, left ventricle | | MR | = mitral regurgitation | | RV | = right ventricular, right ventricle | | SHOCK | = SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (Trial) | | TIMI | = Thrombolysis In Myocardial Infarction | | VSR | = ventricular septal rupture |
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