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
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Abstract
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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.
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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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The first large, randomized trials of fibrinolytic therapy for acute myocardial infarction (MI), which included patients with any electrocardiographic (ECG) findings, observed that the prognosis differed with the presence or absence of ST-segment elevation. Patients with ST-segment depression MIs were at higher risk of early mortality, whereas patients with a normal ECG or nonspecific ECG findings were at lower risk (1–6). Moreover, although there is substantial evidence for a benefit of reperfusion therapy for MI patients with ST-segment elevation (1,7), the best treatment strategy for patients with non-ST-segment elevation MI is less well-defined (8). Similarly, the role of early revascularization for ST-segment elevation MI complicated by cardiogenic shock (CS) has been studied in a randomized clinical trial (9), but the optimal therapy of non-ST-segment elevation MI when CS develops is unknown.
In an international CS registry, patients with primary left ventricular (LV) failure associated with ST-segment depression, T-wave inversion, or previous left bundle branch block (LBBB) were older, developed shock later, and were less likely to undergo coronary angiography and early revascularization, compared with patients who had ST-segment elevation (10). In this small cohort study, the mortality in the two groups was similar. To further evaluate the characteristics of patients with non-ST-segment elevation MI complicated by CS shock and to determine whether the absence of ST-segment elevation is a predictor of in-hospital mortality, we compared MI patients with and without ST-segment elevation in a large registry associated with the SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK? (SHOCK) Trial.
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Methods
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SHOCK Trial Registry.
The SHOCK Trial was a randomized comparison of early percutaneous or surgical revascularization versus initial medical stabilization (including thrombolytic therapy and intra-aortic balloon pumping, where appropriate) for patients with acute MI complicated by CS (9). Patients with suspected CS, either ineligible for participation or eligible but not randomized, were entered into a registry that is described in this supplementary issue of the Journal (11). The institutional committee on human research approved the study protocol at each center.
Patient sample.
This report is based on 881 patients with CS due to primary LV failure, a subset of the 1,190 patients with CS complicating acute MI who were prospectively registered. Of 1,190 patients, five were excluded from this report because of missing ECG data. Of the remaining 1,185 patients, 304 patients had CS due to mechanical complications, cardiac tamponade, a cardiac catheterization laboratory complication, isolated right ventricular dysfunction, severe valvular heart disease, pharmacologic therapy (beta- or calcium-blocking agents) or noncardiac causes, and they were also excluded. The remaining 881 patients comprised the study group and included 152 patients (17.3%) without ST-segment elevation and 729 patients (82.7%) with ST-segment elevation.
Definitions.
ST-segment elevation MI was defined by the presence of at least one of the following: at least two ECG leads with new ST-segment elevation, new Q waves in at least two leads, posterior ST-segment elevation (anterior ST-segment depression in leads V2 or V3 with R/S > 1), posterior Q waves or new LBBB. Non-ST-segment elevation MI was defined by the absence of all of the above criteria. Predominant LV failure was designated as the etiology of CS when no other major shock categories (previously described [11]) were present. Creatine kinase (CK) values reported are the highest recorded (based on three or more measures for 71% of patients).
Data collection.
Data were abstracted from the medical record by the SHOCK study coordinators, who were centrally trained to complete standard study-report forms. Patient characteristics, MI characteristics, hemodynamics, procedure use and vital status at discharge were recorded. Cardiac catheterization and angioplasty reports were sent to the clinical Coordinating Center for abstraction and completion of the standard form. Among patients with predominant LV failure included in this analysis, right-heart catheterization was performed in 567 patients with pulmonary capillary wedge pressure recorded in 532 and cardiac index in 405 patients. Left ventricular ejection fraction was measured during hospitalization on the same day as, or post-shock, by LV angiography (36%), echocardiography (59%), or gated blood-pool scan (5%) in 299 patients. The following variables were available on a maximum 632 patients: ejection fraction, pulmonary artery pressures, history of elevated lipids, peripheral vascular disease, recurrence of ischemic events and re-infarction.
Statistical analysis.
We compared patients with non-ST-segment elevation and ST-segment elevation MI using the Fisher exact test for categorical variables, the Wilcoxon rank-sum test for ordinal and non-normally distributed continuous variables, and the Student t-test for normally distributed continuous variables. For comparison of ordered angiographic variables (stenosis and coronary flow categories), the Mantel-Haenszel test for linear trends was used. In-hospital mortality by groups was analyzed using logistic regression. To determine whether ST-segment elevation (vs. non-ST-segment elevation) was an independent predictor of in-hospital mortality, we constructed a multivariate model adjusting for patient and treatment differences. All variables that were collected on the overall cohort (right heart catheterization, hemodynamic values, and angiographic findings were excluded) and that had a univariate p value  0.20 in univariate group comparison were evaluated. All variables with a final p value 0.05 were retained in the model. All analyses were conducted using SAS (SAS Institute, Cary, North Carolina).
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Results
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Clinical characteristics.
Patients with non-ST-segment elevation MI were significantly older than patients with ST-segment elevation (Table 1). Gender was not associated with non-ST-segment elevation (36% female overall), and there was a similar proportion with prior hypertension, diabetes mellitus, smoking and hyperlipidemia in the two groups. Of note, there were significantly higher rates of prior MI, congestive heart failure (CHF), renal insufficiency, prior bypass surgery and peripheral vascular disease in patients with non-ST-segment elevation MI.
The median times from the index MI to the diagnosis of CS did not differ significantly between patients with non-ST-segment elevation (8.9 h) and those with ST-segment elevation MI (5.8 h) (Table 2). However, the highest CK (median 1,034 IU/L vs. 2,209 IU/L) and ratio of highest CK to the upper limit of normal (median 4.8 vs. 10.6) were significantly lower in the non-ST-segment elevation group. Of these two groups, 3.3% and 40.9%, respectively, received thrombolytic therapy. Of note, in a small subset of patients in whom LV function was measured after the diagnosis of shock, LV ejection fraction was similar between groups.
Hemodynamic characteristics.
The mean heart rates and systolic and diastolic blood pressures did not differ between groups (Table 3). Similarly, in the subset of patients undergoing right-heart catheterization, there was no significant difference between groups in cardiac output, cardiac index or pulmonary capillary wedge pressure.
Angiographic characteristics.
Overall, 52.6% of patients with non-ST-segment elevation and 64.1% of patients with ST-segment elevation MI underwent coronary angiography (p = 0.010). After the onset of CS, the rate of angiography in the non-ST-segment elevation group (40.8%) was lower than that in the ST-segment elevation group (51.5%) (p = 0.020). The severity of coronary disease in patients undergoing coronary angiography is shown in Figure 1. Patients with non-ST-segment elevation MI had zero to single-vessel disease less often than did patients with ST-segment elevation (6.9% vs. 24.8%), with a corresponding increase in triple-vessel disease (76.7% vs. 53.5%), p = 0.001. The prevalence of left main disease was also greater in patients with non-ST-segment elevation MI (26.4% vs. 14.3%, p = 0.014).
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Figure 1 Severity of coronary vessel disease in patients with shock due to LV failure undergoing coronary angiography. No or single-, double-, triple-vessel disease: n = 73 for non-ST-segment elevation and n = 443 for ST-segment elevation MI; left main disease: n = 72 for non-ST-segment elevation and n = 434 for ST-segment elevation MI.
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The culprit artery stenosis responsible for the index MI differed between groups (Table 4). The circumflex was the culprit artery significantly more often in patients with non-ST-segment elevation MI (34.6% vs. 13.4%, p = 0.001), whereas the left anterior descending or right coronary artery was affected less often in this group. Thrombolysis In Myocardial Infarction flow grade and severity of the culprit-artery stenosis were similar in the two groups.
In-hospital revascularization Figure 2.
Figure 2. Angioplasty was performed post shock less often in patients with non-ST-segment elevation MI (17.8% vs. 34%, p = 0.001), but more of these patients underwent bypass surgery post shock (21.1% vs. 13.4%, p = 0.023). Thus, the overall rate of revascularization was similar in both groups (36.8% vs. 41.9%).
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Figure 2 Rates of in-hospital coronary angiography and revascularization after the diagnosis of CS caused by LV failure. CABG = coronary artery bypass surgery; PTCA = percutaneous transluminal coronary angioplasty.
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In-hospital outcome.
Ischemia tended to recur more often in patients with non-ST-segment elevation than in patients with ST-segment elevation MI (25.7% vs. 17.4%, p = 0.058), although the proportion of patients experiencing re-infarction was similar in the groups (6.4% vs. 8.5%). In-hospital mortality also was similar: 62.5% for patients with non-ST-segment elevation and 60.4% for patients with ST-segment elevation MI (ST-segment elevation versus non-ST-segment elevation odds ratio (OR) for death 0.91, 95% confidence interval (CI) 0.64 to 1.31, p = 0.649). After multivariate adjustment for patient age and treatment (intra-aortic balloon, thrombolytic therapy, coronary angiography, and bypass surgery) variables, the OR was in the direction of a survival benefit for patients with non-ST-segment elevation MI, but it remained non-significant (OR 1.30, 95% CI 0.83 to 2.02, p = 0.252).
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Discussion
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Non-ST-segment elevation MI.
Cardiogenic shock continues to be the leading cause of death in patients hospitalized with acute MI (12). Moreover, despite a better understanding of the importance of timeliness in treatment and advances in pharmacologic and mechanical reperfusion therapies that have decreased overall mortality with MI (1,7), the mortality associated with CS complicating acute MI has remained relatively high (10–13). Recent reports indicate a decreasing mortality over time with increasing rates of revascularization (14). The randomized SHOCK Trial revealed a trend toward lower mortality at 30 days, and significantly lower mortality at six months, in patients with MI treated with early revascularization (9). Therefore, it becomes important to identify patients with CS who might benefit from specific therapies.
Of patients presenting with acute MI, about 30% do not have ST-segment elevation (1), and a recent report of an international registry of patients in CS revealed that about 14% of patients with primary LV failure had non-ST-segment elevation MI (10). In fact, the binary classification system of acute MI has evolved from a pathological designation (transmural vs. subendocardial) to an ECG designation (Q wave vs. non-Q wave). However, the increased use of reperfusion therapy has made the clinical distinction between Q wave and non-Q wave MI less apparent. More recently, the direction of ST-segment deviation during acute infarction has been recognized to be a more powerful predictor of clinical outcome than the presence or absence of Q waves (4,15–17). It is also increasingly clear that the pathogenesis, clinical course, prognosis and treatment of patients presenting with non-ST-segment elevation MI differ significantly from those of patients with ST-segment elevation MI (18–20). The striking finding of this study is the high rate of circumflex-artery occlusion as the culprit lesion in patients with non-ST-segment elevation MI, who also had more frequent prior MI and severe multivessel disease. The misclassification of non-ST-segment elevation as "nontransmural" MI leads to a failure to administer reperfusion therapy in the group of patients with "posterior" ST-segment elevation.
Patients with non-ST-segment elevation MI have smaller infarcts (as shown by lower peak CK levels), earlier times to peak CK, pathologic evidence of reperfusion, more subtotal occlusions among those undergoing early angiography (21–23), and more recurrent ischemia, compared with patients who have ST-segment elevation MI (24–26). In addition, clinical and demographic characteristics differ significantly by the presence or absence of ST-segment elevation with MI (20,27). Patients with non-ST-segment elevation MI generally are older, are more often female, and have a higher incidence of diabetes mellitus, hypertension, CHF and prior MI. Furthermore, although early mortality with non-ST-segment elevation MI is lower, the cumulative mortality at one to two years is similar to that of patients with ST-segment elevation, and patients with non-ST-segment elevation MI have more recurrent ischemia and re-infarction (20,25).
Clinical characteristics.
By contrast, the characteristics and outcome of patients with non-ST-segment elevation MI in CS are less clear. In a recent analysis of the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO)-IIb trial, patients with non-ST-segment elevation MI in whom shock developed had a similar mortality but different clinical and angiographic characteristics than CS patients with ST-segment elevation MI (28). Similar to that study, patients in the SHOCK Trial Registry with non-ST-segment elevation MI were older and had a higher incidence of comorbid factors, including CHF, renal insufficiency and peripheral vascular disease. There was a higher incidence of prior MI and bypass surgery, compared with patients having ST-segment elevation MI, although the proportion of female patients was similar in each group. As expected, patients with non-ST-segment elevation received thrombolytic therapy less often than those with ST-segment elevation MI. Yet, the total CK and the ratio of highest CK to the upper limit of normal were lower in patients with non-ST-segment elevation MI. Furthermore, in the smaller subset of patients undergoing measurement of LV function, ejection fraction was similar between groups. The smaller infarcts in patients with non-ST-segment elevation MI may compensate for their higher baseline risk, resulting in the same mortality seen overall in the SHOCK Trial Registry. Similarly, the smaller infarcts in the non-ST-segment elevation group—compared with patients with ST-segment elevation MI—despite having more prior infarctions, may explain the similar LV function and hemodynamic measures observed, including heart rate, filling pressures and cardiac index values.
Angiographic characteristics.
As reported in previous studies, patients with non-ST-segment elevation MI had more multivessel disease and, specifically, more triple-vessel disease than did patients with ST-segment elevation MI (22). It is interesting that the left circumflex was the culprit artery significantly more often in patients with non-ST-segment elevation than in patients with ST-segment elevation MI, and this finding has also been noted in the absence of shock. Of note, most patients with acute MI whose ECG is misclassified are those with acute circumflex or circumflex obtuse marginal artery branch occlusion; infarction of the high lateral or posterolateral walls of the LV may not be detected on the standard 12-lead ECG (23,29). In this setting, the lack of ST-segment elevation may be associated with a total coronary occlusion or transmural (Q wave) infarction. Therefore, patients with non-ST-segment elevation MI represent a heterogeneous group for whom appropriate reperfusion therapy may be withheld. This has important implications, particularly in the setting of CS, where pharmacologic or mechanical reperfusion therapy may be indicated to prevent or treat shock.
In-hospital revascularization.
The role of revascularization for ST-segment elevation or new LBBB MI has previously been evaluated (30–33) and has recently been clarified (9). Emergency early revascularization resulted in a significant reduction in six-month mortality in the randomized SHOCK Trial (9). In the SHOCK Trial Registry, patients with non-ST-segment elevation MI underwent less coronary angiography and less angioplasty after the onset of CS, which was probably secondary to their higher-risk profile and more multivessel disease, but they had similar mortality compared with patients who had ST-segment elevation MI. Similar to studies of non-ST-segment elevation MI patients without shock, we saw a trend toward more recurrent ischemia in shock patients with non-ST-segment elevation MI. Thus, early angiography and appropriate revascularization might reduce recurrent ischemia and enhance outcome in this group of patients. However, the absence of a benefit in patients older than 75 years of age assigned to early revascularization in the SHOCK Trial should be noted.
In-hospital outcome.
Despite the smaller infarcts of patients with non-ST-segment elevation MI, their early mortality was similar to that of patients with ST-segment elevation. This may be a result of the higher-risk profile and possible underuse of potentially beneficial therapies, such as revascularization, in patients with non-ST-segment elevation MI. Alternatively, smaller infarcts and more viable myocardium (as evidenced by more recurrent ischemia) may work together to reduce mortality in this high-risk group. In addition, perhaps in the setting of shock, traditional risk factors for a poor outcome do not further affect mortality.
Study limitations.
These data should be interpreted with caution because potentially confounding factors influencing mortality cannot be expected to be equally distributed among the groups in this registry setting. In addition, we could not separate the group with non-ST-segment elevation MI into those with ST-segment depression, those with (possibly) old LBBB, or other subsets. Although these ECG-defined groups of patients with MI have been shown to have different features and prognoses, comparisons made between the entire group of patients with non-ST-segment elevation MI and those with ST-segment elevation MI remain valid. Conclusions concerning hemodynamic data and LV function should be made in view of the fact that these parameters were available only on a limited number of patients.
Conclusions.
Compared with shock patients who had ST-segment elevation MI, patients with non-ST-segment elevation are older and are more likely to have comorbid disease, prior infarctions and multivessel disease. In about 30% of these patients, the left circumflex is the culprit artery, suggesting that a standard 12-ECG in these patients may show "posterior" elevation. Despite their higher-risk profile, patients with non-ST-segment elevation MI and CS had an in-hospital mortality rate similar to that of patients with ST-segment elevation. The common occurrence of recurrent ischemia and the infrequent use of angiography represent opportunities for earlier intervention, which may enhance outcome. Early reperfusion therapy for circumflex-artery occlusion should be considered when non-ST-segment elevation MI causes CS.
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Footnotes
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Supported by RO1 grants HL50020, HL49970, 1994–99, from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
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Abstract
Methods