CORRESPONDENCE: LETTER TO THE EDITOR
Long-Term Outcome Among Patients With ST-Segment Elevation Myocardial Infarction Complicated by Shock
Marek Roik, MD* and
Grzegorz Opolski, MD, PhD, FESC
* First Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1 a, Warsaw 02-097, Poland (Email: mfroik{at}amwaw.edu.pl).
We read with great interest the study by Singh et al. (1) investigating the long-term outcome and its predictors among patients with ST-segment elevation myocardial infarction (STEMI) complicated by shock. The investigators showed that among patients with cardiogenic shock who survive 30 days after STEMI, annual mortality between 2 and 11 years reaches 2% to 4% for each group. Despite a well-designed study, in our opinion some important issues have not been addressed by the investigators.
The GUSTO (Global Utilization of Streptokinase and Tissue-Type Plasminogen Activator for Occluded Coronary Arteries)–I trial did not exclude patients with cardiogenic shock due to any cause and did not restrict the definition of shock to left ventricular pump failure. In contrast to that, in the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial (2) only patients with acute myocardial infarction who developed cardiogenic shock due to predominant left ventricular failure were eligible. A strategy of early revascularizations resulted in 13.2% absolute and 67% relative improvement in 6 years' survival compared with initial medical stabilization. Among hospital survivors it was shown that older age (hazard ratio [HR]: 1.25/10 years; 95% confidence interval [CI]: 1.02 to 1.52; p = 0.04), creatinine level of 1.9 mg/dl or greater (HR: 1.96; 95% CI: 1.16 to 3.34; p = 0.01), a history of hypertension (HR: 1.56; 95% CI 1.04 to 2.35; p = 0.3), and lower ejection fraction (HR: 1.22/5%, 95% CI: 1.1 to 1.32; p < 0.001) were independently associated with death. After 1 year, the survival curves were parallel among patients with or without shock and annual mortality rate reached 8% versus 10.7% deaths. In a recent study, Brodi et al. (3) compared late survival after primary percutaneous coronary intervention in patients with cardiogenic shock due to right ventricular infarction versus left ventricular pump failure. Patients with shock caused by right ventricular infarction had fewer previous infarctions, less multivessel disease, higher right atrial pressure, and better ejection fraction (57% vs. 32%, p < 0.001). In multivariate analysis, shock caused by right ventricle infarction was a significant and independent predictor of late cardiac survival (HR: 0.28; 95% CI: 0.13 to 0.62; p = 0.002). Another important issue is the prognostic implications of the timing of onset of cardiogenic shock after myocardial infarction. In the TRACE (Trandolapril Cardiac Evaluation) study (4), nearly 60% of cardiogenic shock patients had early shock (0 to 48 h), 11% developed shock at 3 to 4 days, and 30% developed shock at 5 days or more after index myocardial infarction. Patients in whom late shock develops have a twice-higher mortality rate. In opposition to this trial, in the SHOCK trial and registry (5) the in-hospital mortality was higher (75% vs. 56%, p < 0.001), with more rapid death (24-h mortality 40% vs. 17%, p < 0.001) in cardiogenic shock on admission than in delayed cardiogenic shock patients. This raises a question: how many hospital survivors in GUSTO-I developed late shock? In an editorial comment, Hochman and Apolito (6) have raised another important finding that can influence the lower mortality rate in the GUSTO-1 trial in long-term follow-up.
Therefore, we believe that the differences in long-term prognosis between the studies may be determined by the definition of cardiogenic shock, different patient populations, and initial therapy. Also, in an unselected cohort of patients admitted with acute myocardial infarction complicated by shock the mortality is considerably higher than is expected from voluntary-based registries and large-scale clinical trials.
The GUSTO-I trial showed a remarkable long-term prognosis for hospital survivors of cardiogenic shock; however, how to improve the short-term prognosis among unselected patients and help to catch "the long life"—this question is still open.
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1. Singh M, White J, Hasdai D, et al. Long-term outcome and its predictors among patients with ST-segment elevation myocardial infarction complicated by shock: insights from the GUSTO-I trial J Am Coll Cardiol 2007;50:1752-1758.[Abstract/Free Full Text]2. 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] 3. Brodie BR, Stuckey TD, Hansen C, et al. Comparison of late survival in patients with cardiogenic shock due to right ventricular infarction versus left ventricular pump failure following primary percutaneous coronary intervention for ST-elevation acute myocardial infarction Am J Cardiol 2007;99:431-435.[CrossRef][Web of Science][Medline] 4. Lindholm MG, Kober L, Boesgaard C, et al. 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] 5. Jeger RV, Harkness SM, Ramanathan K, et al. Emergency revascularization in patients with cardiogenic shock on admission: a report from the SHOCK trial and registry Eur Heart J 2006;27:664-670.[Abstract/Free Full Text] 6. Hochman JS, Apolito R. The calm after the storm J Am Coll Cardiol 2007;50:1759-1760.[Free Full Text]
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