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J Am Coll Cardiol, 2003; 42:1380-1386, doi:10.1016/S0735-1097(03)01050-7
© 2003 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: CARDIOGENIC SHOCK

Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial

John G. Webb, MD, FACC*,*, April M. Lowe, MS{dagger}, Timothy A. Sanborn, MD, FACC{ddagger}, Harvey D. White, DSc§, Lynn A. Sleeper, ScD{dagger}, Ronald G. Carere, MD, FACC*, Christopher E. Buller, MD, FACC||, S. Chiu Wong, MD, FACC, Jean Boland, MD#, Vlad Dzavik, MD**, Mark Porway, MD, FACC{dagger}{dagger}, Gordon Pate, MB*, Geoffrey Bergman, MD, FACC, Judith S. Hochman, MD, FACC{ddagger}{ddagger} for the SHOCK Investigators

* St. Paul's Hospital, Vancouver, Canada
{dagger} New England Research Institutes, Watertown, Massachusetts, USA
{ddagger} Evanston Northwestern Healthcare, Evanston, Illinois, USA
§ Green Lane Hospital, Auckland, New Zealand
|| Vancouver General Hospital, Vancouver, Canada
New York Presbyterian, New York, New York, USA
# CHR Citadelle, Liege, Belgium
** Toronto General Hospital, Toronto, Canada
{dagger}{dagger} Baystate Medical Center, Springfield, Massachusetts, USA
{ddagger}{ddagger} Division of Cardiology, New York University School of Medicine, New York, New York, USA

Manuscript received January 18, 2003; revised manuscript received March 20, 2003, accepted March 27, 2003.

* Reprint requests and correspondence: Dr. John G. Webb, Director, Cardiac Catheterization and Interventional Cardiology, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6.
webb{at}providencehealth.bc.ca

OBJECTIVES: We examined the clinical, angiographic, and procedural characteristics determining survival after percutaneous coronary intervention (PCI) for cardiogenic shock.

BACKGROUND: The SHOCK (SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK?) trial prospectively enrolled patients with shock complicating acute myocardial infarction (MI). Patients were randomized to a strategy of early revascularization or initial medical stabilization.

METHODS: Patients randomized to early revascularization underwent PCI or bypass surgery on the basis of predefined clinical criteria. Patients randomized to early revascularization who underwent PCI and had angiographic films available for analysis are the subject of this report (n = 82).

RESULTS: The median time from MI to PCI was 11 h. The majority of patients had occluded culprit arteries (Thrombolysis In Myocardial Infarction [TIMI] grade 0 or 1 flow in 62%) and multivessel disease (81%). One-year mortality in PCI patients was 50%. Mortality was 39% if PCI was successful but 85% if unsuccessful (p < 0.001). Mortality was 38% if TIMI flow grade 3 was achieved, 55% with TIMI grade 2 flow, and 100% with TIMI grade 0 or 1 flow (p < 0.001). Mortality was 67% if severe mitral regurgitation was documented. Independent correlates of mortality were as follows: increasing age (p < 0.001), lower systolic blood pressure (p = 0.009), increasing time from randomization to PCI (p = 0.019), lower post-PCI TIMI flow (0/1 vs. 2/3) (p < 0.001), and multivessel PCI (p = 0.040).

CONCLUSIONS: Restoration of coronary blood flow is a major predictor of survival in cardiogenic shock. Benefit appears to extend beyond the generally accepted 12-h post-infarction window. Surgery should be considered in shock patients with severe mitral insufficiency or multivessel disease not amenable to relatively complete percutaneous revascularization.

Abbreviations and Acronyms
  GP = glycoprotein
  MI = myocardial infarction
  PCI = percutaneous coronary intervention
  SHOCK = SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK
  TIMI = Thrombolysis In Myocardial Infarction




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