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CLINICAL RESEARCH: MYOCARDIAL INFARCTION

Long-Term Outcome and its Predictors Among Patients With ST-Segment Elevation Myocardial Infarction Complicated by Shock

Insights 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).

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.

Abbreviations and Acronyms   MI = myocardial infarction   NDI = National Death Index   STEMI = ST-segment elevation myocardial infarction

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