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CLINICAL STUDY

Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry

Timothy A. Sanborn, MD, FACC^*, Lynn A. Sleeper, ScD, Eric R. Bates, MD, FACC, Alice K. Jacobs, MD, FACC, Jean Boland, MD^||, John K. French, PhD, MBChB^¶, Jo Dens, MD, Vladimir Dzavik, MD^**, Sebastian T. Palmeri, MD, FACC, John G. Webb, MD, FACC, Mark Goldberger, MD, FACC, Judith S. Hochman, MD, FACC^|||| for the SHOCK Investigators

^* New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
New England Research Institutes, Watertown, Massachusetts, USA
University of Michigan Medical Center, Ann Arbor, Michigan, USA
Boston Medical Center, Boston, Massachusetts, USA
^|| CHR Citadelle, Liège, Belgium
^¶ Green Lane Hospital, Auckland, New Zealand
Gasthuisberg University Hospital, Leuven, Belgium
^** University of Alberta Hospital, Edmonton, Alberta, Canada
Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
St. Paul’s Hospital, Vancouver, British Columbia, Canada
Montefiore Medical Center, Bronx, New York, USA
^|||| St. Luke’s–Roosevelt Hospital, New York, New York, USA

Manuscript received February 16, 2000; revised manuscript received May 31, 2000, accepted June 7, 2000.

Reprint requests and correspondence: Dr. Timothy A. Sanborn, Cardiology Division, Burch 300, Evanston Hospital, 2650 Ridge Ave, Evanston, Illinois 60201
tsanborn{at}enh.org

OBJECTIVES

We sought to investigate the potential benefit of thrombolytic therapy (TT) and intra-aortic balloon pump counterpulsation (IABP) on in-hospital mortality rates of patients enrolled in a prospective, multi-center Registry of acute myocardial infarction (MI) complicated by cardiogenic shock (CS).

BACKGROUND

Retrospective studies suggest that patients suffering from CS due to MI have lower in-hospital mortality rates when IABP support is added to TT. This hypothesis has not heretofore been examined prospectively in a study devoted to CS.

METHODS

Of 1,190 patients enrolled at 36 participating centers, 884 patients had CS due to predominant left ventricular (LV) failure. Excluding 26 patients with IABP placed prior to shock onset and 2 patients with incomplete data, 856 patients were evaluated regarding TT and IABP utilization. Treatments, selected by local physicians, fell into four categories: no TT, no IABP (33%; n = 285); IABP only (33%; n = 279); TT only (15%; n = 132); and TT and IABP (19%; n = 160).

RESULTS

Patients in CS treated with TT had a lower in-hospital mortality than those who did not receive TT (54% vs. 64%, p = 0.005), and those selected for IABP had a lower in-hospital mortality than those who did not receive IABP (50% vs. 72%, p < 0.0001). Furthermore, there was a significant difference in in-hospital mortality among the four treatment groups: TT + IABP (47%), IABP only (52%), TT only (63%), no TT, no IABP (77%) (p < 0.0001). Patients receiving early IABP (6 h after thrombolytic therapy, n = 72) had in-hospital mortality similar to those with late IABP (53% vs. 41%, n = 64, respectively, p = 0.172). Revascularization rates differed among the four groups: no TT, no IABP (18%); IABP only (70%); TT only (20%); TT and IABP (68%, p < 0.0001); this influenced in-hospital mortality significantly (39% with revascularization vs. 78% without revascularization, p < 0.0001).

CONCLUSIONS

Treatment of patients in cardiogenic shock due to predominant LV failure with TT, IABP and revascularization by PTCA/CABG was associated with lower in-hospital mortality rates than standard medical therapy in this Registry. For hospitals without revascularization capability, a strategy of early TT and IABP followed by immediate transfer for PTCA or CABG may be appropriate. However, selection bias is evident and further investigation is required.

Abbreviations and Acronyms   CABG = coronary artery bypass graft surgery   CK = creatine phosphokinase   CS = cardiogenic shock   IABP = intra-aortic balloon pump   LV = left ventricular, left ventricle   LVEF = left ventricular ejection fraction   MI = myocardial infarction   PTCA = percutaneous transluminal coronary angioplasty   SHOCK = SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?   TT = thrombolytic therapy

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