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CLINICAL STUDY

Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK Trial Registry

Christopher R. Thompson, MD, CM, FACC^*, Christopher E. Buller, MD, FACC, Lynn A. Sleeper, ScD^||, Tracy A. Antonelli, MPH^||, John G. Webb, MD, FACC^*, Wael A. Jaber, MD, James G. Abel, MD, Judith S. Hochman, MD, FACC^¶ for the SHOCK Investigators

^* Division of Cardiology, St. Paul’s Hospital, Vancouver, British Columbia, Canada
Division of Cardiovascular Surgery, St. Paul’s Hospital, Vancouver, British Columbia, Canada
Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
Division of Cardiac Imaging, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^|| New England Research Institutes, Watertown, Massachusetts, USA
^¶ Division of Cardiology, St. Luke’s–Roosevelt Hospital Center and Columbia University, New York, New York, USA

Reprint requests and correspondence: Dr. C.R. Thompson, Director, Cardiology Clinical Research, St. Paul’s Hospital, Room 5134-1081 Burrard Street, Vancouver, B.C., Canada V6Z 1Y6
cthompson{at}Providencehealth.bc.ca

OBJECTIVES

Our objective was to define the outcomes of patients with cardiogenic shock (CS) due to severe mitral regurgitation (MR) complicating acute myocardial infarction (AMI).

BACKGROUND

Methods for early identification and optimal treatment of such patients have not been defined.

METHODS

The SHOCK Trial Registry enrolled 1,190 patients with CS complicating AMI. We compared 1) the cohort with severe mitral regurgitation (MR, n = 98) to the cohort with predominant left ventricular failure (LVF, n = 879), and 2) the MR patients who underwent valve surgery (n = 43) to those who did not (n = 51).

RESULTS

Shock developed early after MI in both the MR (median 12.8 h) and LVF (median 6.2 h) cohorts. The MR patients were more often female (52% vs. 37%, p = 0.004) and less likely to have ST elevation at shock diagnosis (41% vs. 63%, p < 0.001). The MR index MI was more frequently inferior (55% vs. 44%, p = 0.039) or posterior (32% vs. 17%, p = 0.002) than that of LVF and much less frequently anterior (34% vs. 59%, p < 0.001). Despite having higher mean LVEF (0.37 vs. 0.30, p = 0.001) the MR cohort had similar in-hospital mortality (55% vs. 61%, p = 0.277). The majority of MR patients did not undergo mitral valve surgery. Those undergoing surgery exhibited higher mean LVEF than those not undergoing surgery; nevertheless, 39% died in hospital.

CONCLUSIONS

The data highlight opportunities for early identification and intervention to potentially decrease the devastating mortality and morbidity of severe post-myocardial infarction MR.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CS = cardiogenic shock   CABG = coronary artery bypass graft surgery   ECG = electrocardiogram, electrocardiographic   IABP = intra-aortic balloon pump   LVF = left ventricular failure   MR = severe mitral regurgitation   PTCA = percutaneous transluminal coronary angioplasty   SHOCK = SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK?

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