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CLINICAL STUDY

Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry

Alice K. Jacobs, MD, FACC^*, John K. French, PhD, MBChB, Jacques Col, MD, Lynn A. Sleeper, ScD, James N. Slater, MD, FACC^||, Louis Carnendran, MD^||, Jean Boland, MD^¶, Xianjiao Jiang, MS, Thierry LeJemtel, MD, FACC^**, Judith S. Hochman, MD, FACC^|| for the SHOCK Investigators

^* Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
Green Lane Hospital, Auckland, New Zealand
Cliniques Universitaires, Brussels, Belgium
New England Research Institutes, Watertown, Massachusetts, USA
^|| St. Luke’s–Roosevelt Hospital, New York, New York, USA
^¶ CHR Citadelle, Liège, Belgium
^** Albert Einstein College of Medicine, Bronx, New York, USA

Manuscript received February 16, 2000; revised manuscript received June 19, 2000, accepted June 20, 2000.

Reprint requests and correspondence: Dr. Alice K. Jacobs, Boston Medical Center, 88 East Newton St., Boston, Massachusetts 02118
alice.jacobs{at}bmc.org

OBJECTIVES

We sought to determine the outcomes of patients with cardiogenic shock (CS) complicating non-ST-segment elevation acute myocardial infarction (MI).

BACKGROUND

Such patients represent a high-risk (ST-segment depression) or low-risk (normal or nonspecific electrocardiographic findings) group for whom optimal therapy, particularly in the setting of shock, is unknown.

METHODS

We assessed characteristics and outcomes of 881 patients with CS due to predominant left ventricular (LV) dysfunction in the SHOCK Trial Registry.

RESULTS

Patients with non-ST-segment elevation MI (n = 152) were significantly older and had significantly more prior MI, heart failure, azotemia, bypass surgery, and peripheral vascular disease than patients with ST-elevation MI (n = 729). On average, the groups had similar in-hospital LV ejection fractions (30%), but patients with non-ST-elevation MI had a lower highest creatine kinase and were more likely to have triple-vessel disease. Among patients selected for coronary angiography, the left circumflex artery was the culprit vessel in 34.6% of non-ST-elevation versus 13.4% of ST-elevation MI patients (p = 0.001). Despite having more recurrent ischemia (25.7% vs. 17.4%, p = 0.058), non-ST-elevation patients underwent angiography less often (52.6% vs. 64.1%, p = 0.010). The proportion undergoing revascularization was similar (36.8% for non-ST-elevation vs. 41.9% ST-elevation MI, p = 0.277). In-hospital mortality also was similar in the two groups (62.5% for non-ST-elevation vs. 60.4% ST-elevation MI). After adjustment, ST-segment elevation MI did not independently predict in-hospital mortality (odds ratio, 1.30; 95% confidence interval, 0.83 to 2.02; p = 0.252).

CONCLUSIONS

Patients with CS and non-ST-segment elevation MI have a higher-risk profile than shock patients with ST-segment elevation, but similar in-hospital mortality. More recurrent ischemia and less angiography represent opportunities for earlier intervention, and early reperfusion therapy for circumflex artery occlusion should be considered when non-ST-elevation MI causes CS.

Abbreviations and Acronyms   CHF = congestive heart failure   CK(-MB) = creatine kinase (-MB)   CS = cardiogenic shock   ECG = electrocardiogram, electrocardiographic   LBBB = left bundle branch block   LV = left ventricular, left ventricle   MI = myocardial infarction   SHOCK = SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?

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