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Early Mechanical Revascularization Recommended for MI with Cardiogenic Shock

Increased use of primary percutaneous coronary intervention has reduced mortality significantly in patients with myocardial infarction complicated by cardiogenic shock.

In 1999, the American College of Cardiology and American Heart Association recommended early mechanical revascularization for patients with acute myocardial infarction complicated by cardiogenic shock. Have mortality rates and use of mechanical revascularization procedures changed since then? Using data from the National Registry of Myocardial Infarction, researchers examined the question in a prospective observational study of 293,633 patients with ST-segment–elevation MI or left bundle-branch block MI who presented to 755 hospitals with revascularization capability from January 1995 to May 2004. Mechanical revascularization procedures included percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and intra-aortic balloon pump (IABP).

Overall, 25,311 patients (8.6%) had cardiogenic shock, which was diagnosed at presentation in 7356 (29%) and developed during hospitalization in the remainder. During the study period, use of primary PCI increased significantly, from 27.4% to 54.4%, whereas rates of CABG and IABP were unchanged. Use of fibrinolytic therapy decreased. There were no significant differences in rates of change in use of mechanical revascularization during the study period. The rate of in-hospital cardiogenic shock mortality decreased significantly, from 60.3% to 47.9%. In multivariate analysis, primary PCI was independently associated with lower mortality (adjusted odds ratio, 0.46).

Comment: Use of PCI in patients with cardiogenic shock after ST-elevation MI or left bundle-branch block MI was associated with significantly improved survival. Better adherence to these evidence-based guidelines for early mechanical revascularization would likely lead to further improvement in survival.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine October 25, 2005

Citation(s):

Babaev A et al. Trends in management and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock. JAMA 2005 Jul 27; 294:448-54.

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