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CLINICAL STUDY

Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry

James Slater, MD, FACC^*, Robert J. Brown, MD^*, Tracy A. Antonelli, MPH, Venu Menon, MD, FACC^*, Jean Boland, MD, Jacques Col, MD, Vladimir Dzavik, MD^||, Mark Greenberg, MD, FACC^¶, Mark Menegus, MD, FACC^¶, Cliff Connery, MD^*, Judith S. Hochman, MD, FACC^* for the SHOCK Investigators

^* St. Luke’s-Roosevelt Medical Center, New York, New York, USA
New England Research Institutes, Watertown, Massachusetts, USA
Hopital de la Citadelle, Liège, Belgium
Clinique Universitaire St. Luc, Brussels, Belgium
^|| University of Alberta Hospital, Edmonton, Alberta, Canada
^¶ Montefiore Medical Center-Albert Einstein College of Medicine, Bronx, New York, USA

Manuscript received February 16, 2000; revised manuscript received June 7, 2000, accepted June 13, 2000.

Reprint requests and correspondence: Dr. James Slater, Division of Cardiology, St. Luke’s/Roosevelt Hospital, 1111 Amsterdam Ave., New York, NY 10025
jslater{at}slrhc.org

OBJECTIVES

We sought to compare the characteristics and outcomes of patients with acute myocardial infarction (MI) and cardiogenic shock (CS) caused by rupture of the ventricular free wall or tamponade versus shock from other causes.

BACKGROUND

Free-wall rupture is a recognized cause of mortality in patients with acute MI. Some of these patients present subacutely, which provides an opportunity for intervention. Recognition of factors that distinguish them from the overall shock cohort would be beneficial.

METHODS

The international SHOCK Trial Registry enrolled patients concurrently with the randomized SHOCK Trial. Thirty-six centers consecutively enrolled all patients with suspected CS after MI, regardless of trial eligibility.

RESULTS

Of the 1,048 patients studied, 28 (2.7%) had free-wall rupture or tamponade. These patients had less pulmonary edema, less diabetes, less prior MI, and less prior congestive heart failure (all p < 0.05). They more often had new Q waves in two or more leads (51.9% vs. 31.5%, p < 0.04), but MI location and time to shock onset after MI did not differ. Of patients with rupture or tamponade, 75% had pericardial effusions. No hemodynamic characteristics identified patients with rupture/tamponade. Most patients with rupture/tamponade had surgery and/or pericardiocentesis (27/28); their in-hospital survival rate was identical to that of the group overall (39.3%). Women and older patients with rupture/tamponade tended to survive intervention less often.

CONCLUSIONS

Free-wall rupture and tamponade may present as CS after MI, and survival after intervention is similar to that of the overall shock cohort. All patients with CS after MI should have echocardiography in order to detect subacute rupture or tamponade and initiate appropriate interventions.

Abbreviations and Acronyms   BP = blood pressure   CS = cardiogenic shock   LV = left ventricular, left ventricle   MI = myocardial infarction   MR = mitral regurgitation   RV = right ventricular, right ventricle   SHOCK = SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (trial)

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