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CLINICAL STUDY

Implications of the timing of onset of cardiogenic shock after acute myocardial infarction: a report from the SHOCK Trial Registry

John G. Webb, MD, FACC^a, Lynn A. Sleeper, ScD, Christopher E. Buller, MD, FACC, Jean Boland, MD, Angela Palazzo, MD^||, Elizabeth Buller, RN^a, Harvey D. White, DSc^¶, Judith S. Hochman, MD, FACC^|| for the SHOCK Investigators

^a St. Paul’s Hospital, Vancouver, British Columbia, Canada
New England Research Institutes, Watertown, Massachusetts, USA
Vancouver General Hospital, Vancouver, British Columbia, Canada
CHR Citadelle, Liège, Belgium
^|| St. Luke’s–Roosevelt Hospital Center, New York, New York, USA
^¶ Green Lane Hospital, Auckland, New Zealand

Manuscript received February 16, 2000; revised manuscript received June 2, 2000, accepted June 7, 2000.

Reprint requests and correspondence: Dr. John Webb, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6
webb{at}providencehealth.bc.ca

OBJECTIVES

We sought to examine the implications of the timing of onset of cardiogenic shock (CS) after acute myocardial infarction (MI).

BACKGROUND

Little information is available about the relationships between timing, clinical substrate, management and outcomes of shock.

METHODS

The multinational SHOCK Trial Registry enrolled MI patients with CS from 1993 to 1997. Cardiogenic shock was predominantly attributable to left ventricular (LV) failure in 815 Registry patients for whom temporal data were available. We examined factors related to the timing of shock onset and the relation of temporal onset to in-hospital outcomes.

RESULTS

Overall, shock developed a median of 6.2 h after MI symptom onset. Shock onset varied by culprit artery: left main, median 1.7 h; right, 3.5 h; circumflex, 3.9 h; left anterior descending (LAD), 11.0 h; saphenous vein graft, 10.9 h (p = 0.025). Early shock (<24 h) occurred in 74.1% and was associated with chest pain at shock onset, ST-segment elevation in two or more leads, multiple infarct locations, inferior MI, left main disease and smoking. Late shock (24 h) was associated with recurrent ischemia, Q waves in two or more leads and LAD culprit vessel. Mortality was higher in patients with early versus late shock (62.6% vs. 53.6%, p = 0.022).

CONCLUSIONS

Shock onset after acute MI occurred within 24 h in 74% of the patients with predominant LV failure. Mortality was slightly higher in patients developing shock early rather than later. Many factors influence when shock develops, which has implications for its management.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CS = cardiogenic shock   CK-MB = creatine kinase (-MB fraction)   ECG = electrocardiogram, electrocardiographic   LAD = left anterior descending (artery)   LV = left ventricular, left ventricle   PTCA = percutaneous transluminal coronary angioplasty   RV = right ventricular, right ventricle   SHOCK = SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?

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