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Long-Term Benefits of Early Revascularization for Cardiogenic Shock

Benefits found at 1 year in the original SHOCK trial persist at 3 and 6 years.

Cardiogenic shock is the leading cause of death in patients hospitalized with acute myocardial infarction (AMI). In the international, randomized Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial, early revascularization led to a 13% absolute reduction in 1-year mortality. The SHOCK investigators now report outcomes at 3-year and 6-year follow-up.

The SHOCK trial enrolled 302 AMI patients who developed cardiogenic shock due to predominant left ventricular failure within 36 hours after AMI onset. Patients randomized to early revascularization underwent percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) as quickly as possible and within 6 hours after randomization. For patients randomized to medical stabilization, thrombolytic therapy was recommended (used in 63%), and PCI or CABG was allowed at least 54 hours after randomization (used in 25%). The 13% absolute survival difference at 1 year in favor of early revascularization was sustained at 3 years and 6 years. Overall survival rates at 6 years were 32.8% in the early revascularization group and 19.6% in the medical stabilization group. The annualized death rates for the 1-year survivors in the two groups were 8.3% vs. 14.3% per 100 patient-years, respectively.

Comment: Early revascularization led to a 67% improvement in 6-year survival in patients with AMI complicated by cardiogenic shock. This translates to one life saved for just eight patients treated. These results mandate direct admission or immediate transfer of patients in cardiogenic shock to tertiary care centers that can provide early revascularization and intensive care.

— John A. Marx, MD, FAAEM, FACEP

Published in Journal Watch Emergency Medicine July 14, 2006

Citation(s):

Hochman JS et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA 2006 Jun 7; 295:2511-5.

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