CLINICAL RESEARCH: MYOCARDIAL INFARCTION
Long-Term Outcome and its Predictors Among Patients With ST-Segment Elevation Myocardial Infarction Complicated by ShockInsights From the GUSTO-I Trial
Mandeep Singh, MD*,
Jennifer White, MS ,
David Hasdai, MD ,
Patricia K. Hodgson, BA,
Peter B. Berger, MD ,
Eric J. Topol, MD||,
Robert M. Califf, MD and
David R. Holmes, Jr, MD*,*
* Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Duke Clinical Research Institute, Durham, North Carolina
Rabin Medical Center, Petah Tikva, Israel
Geisinger Clinic, Danville, Pennsylvania
|| Scripps Research Institute, La Jolla, California.
Manuscript received January 26, 2007;
revised manuscript received April 16, 2007,
accepted April 30, 2007.
* Reprint requests and correspondence: Dr. David R. Holmes, Jr., Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905. (Email: holmes.david{at}mayo.edu).
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Abstract
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Objectives: This study sought to assess long-term outcome and determine its predictors among 30-day survivors of cardiogenic shock.
Background: Patients with cardiogenic shock have high in-hospital and 30-day mortality, but there are little data about those who survive beyond 30 days.
Methods: We analyzed baseline, in-hospital, and survival data from patients in the U.S. with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock enrolled in the GUSTO (Global Utilization of Streptokinase and Tissue-Type Plasminogen Activator for Occluded Coronary Arteries)-I trial and compared them with patients in the same trial who did not have shock.
Results: Of 22,883 patients enrolled in the U.S., shock occurred in 1,891 (8.3%); 953 (50.4%) survived 30 days and 527 (27.8%) survived 11 years. Of 20,992 U.S. patients without shock, 20,360 (96.9%) survived 30 days and 14,131 (67.3%) survived 11 years. After the first year, 2% to 4% of patients died each year regardless of whether they had cardiogenic shock. Using Cox proportional hazards models, we were able to predict long-term mortality in all U.S. GUSTO-I 30-day survivors from their baseline demographics and in-hospital complications. The strongest predictors were diabetes mellitus, cardiogenic shock, hypertension, previous myocardial infarction, current smoking, anterior infarct, higher Killip class, higher heart rate, and older age; patients >75 years were at highest risk. Percutaneous revascularization during the index hospitalization was associated with a reduced risk of death.
Conclusions: Among patients with cardiogenic shock who survive 30 days after STEMI, annual mortality rates of 2% to 4% approximate those of patients without shock.
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Abbreviations and Acronyms
| | MI = myocardial infarction | | NDI = National Death Index | | STEMI = ST-segment elevation myocardial infarction |
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Cardiogenic shock is of great interest, from its epidemiology and pathophysiology to therapeutic strategies when it complicates ST-segment elevation myocardial infarction (STEMI) (1–5). Shock accounts for two-thirds of all in-hospital mortality from STEMI, most within the first 30 days, although it occurs in only 4% to 7% of patients (6). Little is known about 30-day survivors of shock.
Predictors of short-term and 1-year outcomes in patients with cardiogenic shock have been described (1,7). Few publications report long-term outcome or predictors, although such data would help optimize treatment strategies (8,9).
The GUSTO (Global Utilization of Streptokinase and Tissue-Type Plasminogen Activator for Occluded Coronary Arteries)-I trial presents an opportunity to evaluate long-term outcome in fibrinolytic-eligible patients with and without cardiogenic shock (10). We describe 11-year outcomes of patients with STEMI with and without cardiogenic shock enrolled in the U.S. in the GUSTO-I trial who survived 30 days after the index event.
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Methods
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Study population.
The GUSTO-I trial was a multicenter, multinational trial of 41,021 patients with STEMI who presented with  1 mm ST-segment elevation in 2 limb leads or 2 mm in 2 contiguous precordial leads 20 min to 6 h after symptom onset between 1990 and 1993 (10). Exclusion criteria were previous stroke, active bleeding, previous treatment with streptokinase or anistreplase, recent trauma or major surgery, previous participation in the trial, or noncompressible vascular punctures. Patients with severe, uncontrolled hypertension (systolic blood pressure 180 mm Hg, unresponsive to therapy) had a relative contraindication to enrollment. There was no upper age limit. The primary end point was all-cause 30-day mortality. Patients gave informed consent, and the institutional review board at each hospital approved the protocol.
The GUSTO-I trial did not exclude patients with cardiogenic shock due to any cause and thus did not restrict the definition of shock to left ventricular pump failure. Shock was defined as systolic blood pressure <90 mm Hg for 1 h not responsive to fluid administration alone, thought to be secondary to cardiac dysfunction, and associated with signs of hypoperfusion or cardiac index  2.2 l/min/mm2 and pulmonary capillary wedge pressure >18 mm Hg.
Follow-up.
To obtain long-term outcome data from the GUSTO-I trial, we used the National Death Index (NDI), restricting us to following up only patients from the U.S.
For all U.S. patients who survived 30 days, specific data (Social Security number, birth date, gender, first name, last name) were submitted to the NDI and matched against its records to eliminate patients who had died in the interim. When all data elements matched precisely, patients received high probability scores from the NDI, and we considered them nonsurvivors. Occasionally, the NDI assigned slightly lower probabilities to patients who matched on most but not all of the elements (e.g., a minor difference in the spelling of a patient’s last name but all other factors matched exactly). We also considered such patients to be late deaths. Minimum follow-up for the surviving patients was 9.9 years; 95% were followed up for at least 11 years. Events were censored at 11 years for this analysis.
Statistical analysis.
We present stratified Kaplan-Meier estimates for mortality rates by baseline characteristics and index hospitalization events. For continuous variables, suitable cut points were chosen based on the distribution of the data.
Univariable analysis for trends was performed with Cox proportional hazard models. For categorical variables, indicator variables were formed. Univariable models to test categorical variables with more than 2 classes used all indicators less 1 category for the reference group. In the case of myocardial infarction (MI) location, patients were assigned to the hierarchy of anterior, inferior, and other. Results were interpreted as statistically significant when p < 0.05. Overall long-term mortality was depicted with 95% confidence intervals using the Kaplan-Meier method.
Multivariable Cox proportional hazards survival modeling techniques were used to develop a predictive model for long-term mortality risk. All variables listed in Tables 1 and 2
 were considered in the model. A stepwise selection process was used, augmented by bootstrap techniques to alleviate shortcomings of stepwise selection (11,12). The process consisted of creating 200 bootstrap populations using random selection of study patients, with replacement. Stepwise Cox regression models were run on all bootstrap samples, and factors were confirmed for inclusion in the final model based on the overall frequency of their retention in the models. This method was used in an iterative fashion to refine and confirm selection decisions.
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Table 1 Kaplan-Meier Mortality Estimates at 11 Years for All GUSTO-I Trial 30-Day Survivors in the U.S. Stratified by Baseline Characteristics
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Table 2 Kaplan-Meier Mortality Estimates for All GUSTO-I Trial 30-Day Survivors in the U.S. Based on Events During Index Hospitalization
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Linearity assumptions were checked, and transformations of continuous variables were created as needed. For all continuous independent variables, a restricted cubic spline was fit and plotted against the dependent variable (outcome of death) (13). Plots of the spline-transformed continuous variables and the log-hazard ratio for death were produced. When these plots showed a linear relationship, no transformations were considered. If the plots depicted nonlinear relationships, simple transformations such as inverse, polynomial, natural logarithm, or linear splines were pursued. The only continuous variable retained in the final multivariable model for long-term survival was age. The transformation that worked best was a linear spline with the cut point at age 55 years; this transformation forms 2 independent continuous variables at the point where the relationship to outcome changes.
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Results
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Of the 22,883 U.S. patients, 1,891 (8.3%) arrived in or developed shock during the index hospitalization. At 30 days, 20,360 patients (88.9%) without and 953 (50.4%) with shock were alive; their baseline characteristics are presented in Table 3. After a median of 11 years, 14,131 30-day survivors (69.4%) without and 527 (55.2%) with shock remained alive.
Among all 30-day survivors, risk factors for 11-year mortality were as expected: older age, anterior MI, worse Killip class, higher heart rate, and adverse medical history (Table 1). Patients with in-hospital complications were more likely to die in the ensuing 11 years, whereas those receiving percutaneous revascularization during the index hospitalization were less likely to die (Table 2).
For all 30-day survivors, Figure 1
shows hazard ratio results of univariable Cox regression modeling of the variables associated with higher long-term mortality, which did not differ between patients with and without shock. Increasing age, lower body weight, comorbid conditions, adverse history, anterior MI, in-hospital complications, and longer hospital stay were all associated with adverse long-term prognosis. Killip class I versus IV at baseline and coronary angioplasty during index hospitalization were associated with long-term survival.
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Figure 1 Hazard Ratios for All 30-Day Survivors
Hazard ratios with (red circles) and without (blue squares) cardiogenic shock. Factors analyzed include baseline characteristics, cardiac history, treatment group, and procedures undergone during index hospitalization. All continuous variables (age, weight, height, heart rate, and systolic and diastolic blood pressure) were measured in units of 1 (e.g., respectively, 1 year, 1 kg, 1 cm, 1 beat/min, and 1 mm Hg), so that patients with a variable that measured 1 U greater than another patient had a hazard of mortality as reflected in the figure. For example, a nonshock 65-year-old patient had a 1.06 greater hazard of dying than a nonshock 64-year-old patient. BP = blood pressure; CABG = coronary artery bypass grafting; CVD = cerebrovascular disease; dia = diastolic; IABP = intra-aortic balloon pump; IV Hep = intravenous heparin; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty; SK = streptokinase; SubQ Hep = subcutaneous heparin; sys = systolic; t-PA = tissue plasminogen activator.
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For all patients, regardless of shock status, age >75 years at enrollment was associated with high mortality at 30 days (10.9% nonshock and 68.1% shock patients) and, among 30-day survivors, at 11 years (68.2% and 65.6%, respectively) (Table 4).
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Table 4 30-Day and Long-Term Mortality for All GUSTO-I Trial Patients in the U.S. Stratified by Shock Status and Age
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Figure 2
depicts the Kaplan-Meier curves for 11-year mortality for all 30-day survivors. Beginning in the second year, mortality rates were 2% to 4% per year for all patients regardless of shock status (Fig. 3).
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Figure 2 Kaplan-Meier Mortality Curve in 30-Day Survivors of STEMI
The Kaplan-Meier mortality estimate at 11 years is 44.8% (95% confidence interval 41.6 to 47.9) in patients with (red line)and 30.6% (95% confidence interval 29.9 to 31.2) in patients without (blue line) shock. STEMI = ST-segment elevation myocardial infarction.
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Figure 3 Bar Graph Showing Annual Mortality in STEMI Patients Presenting With and Without Shock
Mortality rates beyond the first year are similar. STEMI = ST-segment elevation myocardial infarction.
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For all 30-day survivors, we used multivariable Cox proportional hazard regression analysis to determine the influence of baseline clinical variables and revascularization on long-term outcome. Table 5
shows variables associated with long-term mortality: shock, hypertension, diabetes, current smoking, anterior MI, previous MI, higher heart rate, and worse Killip class. The influence of increasing age had greater impact on outcome for patients 55 years at randomization than on those <55 years.
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Discussion
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The most important finding of the present study is that the annual mortality of 2% to 4% was similar among U.S. GUSTO-I trial patients with and without cardiogenic shock 2 years to 11 years after STEMI. A second notable finding is that the predictors of long-term outcome were similar regardless of shock status, underscoring the need for aggressive strategies to lower the early hazard associated with shock.
This annual mortality rate of 2% to 4% is similar to 10-year data from the ISIS (International Study of Infarct Survival)-2 trial, with annual mortality of approximately 4% after the first year irrespective of shock status (14). The annual mortality in similar patients enrolled in the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico)-I study was 3.6% (15).
Two studies have published 1-year survival data in shock patients (1,7). The GUSTO-I trial reported survival of 88% among all shock patients worldwide who survived 30 days; survival was 97% in patients without shock (1). The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial of patients with predominantly left ventricular failure reported 1-year survival of 46.7% in the early revascularization group, significantly better than 33.6% in the initial medical stabilization group (7).
Six-year follow-up data are available for the SHOCK and TRACE (Trandolapril Cardiac Evaluation) studies (16,17). The SHOCK study survival was 20% and 33% for, respectively, the early revascularization and initial stabilization groups, whereas TRACE study survival was 55% in nonshock and 12% in shock patients. By contrast, GUSTO-I trial 11-year survival was 67% in nonshock and 28% in shock patients.
The favorable long-term outlook for U.S. GUSTO-I trial patients with shock 2 to 11 years after hospital dismissal was not anticipated. Shock has traditionally been thought to be the result of an irreversible loss of a major amount of left ventricular myocardium, leading to high mortality. However, several observations have failed to support this concept. First, the average ejection fraction in the SHOCK trial was 29% (7). Second, at 1 year, many survivors of cardiogenic shock have good functional status (8). It may be that resolution of severe ischemia and/or neurohormonal abnormalities can explain the potential reversibility of shock. New evidence points to involvement of a systemic inflammatory response, activation of complement, release of cytokines, and expression of inducible nitric oxide synthase in the pathogenesis and outcome of patients presenting with cardiogenic shock (6).
We found the significant predictors of long-term mortality to include expected factors: advancing age, traditional risk factors (including current smoking), and evidence of a large infarct or left ventricular dysfunction. These variables also adversely affected prognosis at 1 year with the exception of current smoking; there is no cogent explanation for this latter observation. Patients who continued to smoke likely fared better in the short term, as shown by less need for additional revascularization procedures (18,19). During longer periods, however, smokers have higher adverse cardiovascular events (19). The other predictors of long-term mortality in GUSTO-I trial 30-day survivors are similar to risk factors in patients presenting without ST-segment elevation and cardiogenic shock (20–22).
The SHOCK investigators noted an age–treatment interaction so that a treatment benefit was apparent only for patients <75 years, among whom 1-year survival was 55% (early revascularization) versus 33% (initial medical stabilization). Current American College of Cardiology/American Heart Association guidelines recommend the use of intra-aortic balloon pumping and early surgical or percutaneous revascularization for suitable shock patients <75 years if it can be performed within 18 h of shock (23). Because the GUSTO-I trial had no exclusion criterion for older age, we were able to observe patients >75 years at enrollment, a subgroup not addressed in contemporary guidelines. Among all U.S. patients >75 years with cardiogenic shock who survived 30 days, the hazard ratio for 11-year mortality was 2.05. Older age itself carried substantial risk, as 68.2% of nonshock and 65.6% of shock patients who survived the first 30 days died by 11 years.
Study limitations.
Our results pertain only to patients who presented with STEMI and were treated with fibrinolysis. Thus, caution is urged in extrapolating these results to shock patients who are fibrinolytic-ineligible and to patients with shock after non-STEMI. Given the use of the NDI to determine how many patients from the GUSTO-I trial had died, there were limitations to the follow-up data; information about nonfatal cardiovascular events, other medical conditions and treatments, or the frequency with which patients underwent revascularization after 30 days could not be collected.
Another limitation is the derivation from an older dataset. With advances in technology, pharmacotherapy, and management of patients presenting with STEMI including cardiogenic shock, long-term outcomes from this study may be less relevant today. Although advances in primary angioplasty and adjunctive pharmacotherapy may make our results less applicable, this study provides a benchmark against which current strategies can be compared.
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Footnotes
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The GUSTO-I study was funded by Bayer, CIBA-Corning Diagnostics, Genentech, ICI Pharmaceuticals, and Sanofi Pharmaceuticals. Dr. Topol was chairman of the study, Dr. Califf was the principal investigator, and Dr. Holmes was a regional director. Each of their institutions received funding through contractual relationships, Duke and Cleveland Clinic with the 5 sponsors and Mayo Clinic with the Cleveland Clinic, which was the Executive Center for the GUSTO-I trial. The GUSTO Steering Committee published a manuscript about patient safety and conflict of interest: J Am Coll Cardiol 1992;19:1123–8.
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References
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1. Berger PB, Tuttle RH, Holmes Jr. DR, et al. One-year survival among patients with acute myocardial infarction complicated by cardiogenic shock, and its relation to early revascularization: results from the GUSTO-I trial Circulation 1999;99:873-878.[Abstract/Free Full Text]2. Chen EW, Canto JG, Parsons LS, et al. Relation between hospital intra-aortic balloon counterpulsation volume and mortality in acute myocardial infarction complicated by cardiogenic shock Circulation 2003;108:951-957.[Abstract/Free Full Text] 3. Dzavik V, Sleeper LA, Cocke TP, et al. Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK trial registry Eur Heart J 2003;24:828-837.[Abstract/Free Full Text] 4. Hasdai D, Holmes Jr. DR, Califf RM, et al. GUSTO Investigators Cardiogenic shock complicating acute myocardial infarction: predictors of deathGlobal Utilization of Streptokinase and Tissue-Plasminogen Activator for Occluded Coronary Arteries. Am Heart J 1999;138:21-31.[CrossRef][Web of Science][Medline] 5. Hasdai D, Topol EJ, Califf RM, Berger PB, Holmes Jr DR. Cardiogenic shock complicating acute coronary syndromes Lancet 2000;356:749-756.[CrossRef][Web of Science][Medline] 6. Hochman JS. Cardiogenic shock complicating acute myocardial infarction: expanding the paradigm Circulation 2003;107:2998-3002.[Free Full Text] 7. Hochman JS, Sleeper LA, White HD, et al. One-year survival following early revascularization for cardiogenic shock JAMA 2001;285:190-192.[Abstract/Free Full Text] 8. Lee L, Erbel R, Brown TM, Laufer N, Meyer J, O’Neill WW. Multicenter registry of angioplasty therapy of cardiogenic shock: initial and long-term survival J Am Coll Cardiol 1991;17:599-603.[Abstract] 9. Tedesco JV, Williams BA, Wright RS, et al. Baseline comorbidities and treatment strategy in elderly patients are associated with outcome of cardiogenic shock in a community-based population Am Heart J 2003;146:472-478.[CrossRef][Web of Science][Medline] 10. The GUSTO Investigators An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction N Engl J Med 1993;329:673-682.[Abstract/Free Full Text] 11. Stone CJ, Koo CY. Additive splines in statistics Proc Stat Comp Sect Am Statist Assoc 1985:45-48. 12. Altman DG, Andersen PK. Bootstrap investigation of the stability of a Cox regression model Stat Med 1988;8:771-783.[CrossRef][Web of Science] 13. Sauerbrei W, Shumacher M. A bootstrap resampling procedure for model building: application to the Cox regression model Stat Med 1992;11:2093-2109.[Web of Science][Medline] 14. Baigent C, Collins R, Appleby P, Parish S, Sleight P, Peto R, The ISIS-2 (Second International Study of Infarct Survival) collaborative group ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither BMJ 1998;316:1337-1343.[Abstract/Free Full Text] 15. Franzosi MG, Santoro E, De Vita C, et al. Ten-year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction: results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto-1 study Circulation 1998;98:2659-2665.[Abstract/Free Full Text] 16. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction JAMA 2006;295:2511-2515.[Abstract/Free Full Text] 17. Lindholm MG, Kober L, Boesgaard S, Torp-Pedersen C, Aldershvile J, TRACE Study Group Cardiogenic shock complicating acute myocardial infarction: prognostic impact of early and late shock development Eur Heart J 2003;24:258-265.[Abstract/Free Full Text] 18. Bowers TR, Terrien EF, O’Neill WW, Sachs D, Grines CL. Effect of reperfusion modality on outcome in nonsmokers and smokers with acute myocardial infarction (a Primary Angioplasty in Myocardial Infarction [PAMI] substudy)PAMI Investigators. Am J Cardiol 1996;78:511-515.[CrossRef][Web of Science][Medline] 19. Hasdai D, Lerman A, Rihal CS, et al. Smoking status and outcome after primary coronary angioplasty for acute myocardial infarction Am Heart J 1999;137:612-620.[CrossRef][Web of Science][Medline] 20. Jacobs AK, French JK, Col J, et al. Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial RegistryShould we emergently revascularize occluded coronaries for cardiogenic shock?. J Am Coll Cardiol 2000;36:1091-1096.[Abstract/Free Full Text] 21. Holmes Jr. DR, Berger PB, Hochman JS, et al. Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation Circulation 1999;100:2067-2073.[Abstract/Free Full Text] 22. Mukherjee D, Fang J, Chetcuti S, Moscucci M, Kline-Rogers E, Eagle KA. Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes Circulation 2004;109:745-749.[Abstract/Free Full Text] 23. Antman EM. New guidelines for ST elevation myocardial infarction Timely Top Med Cardiovasc Dis 2004;8:E11.
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Abstract
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