Elsevier

American Heart Journal

Volume 152, Issue 4, October 2006, Pages 686-692
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
Interhospital transfer for early revascularization in patients with ST-elevation myocardial infarction complicated by cardiogenic shock—a report from the SHould we revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) trial and registry

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Background

Early revascularization (ERV) in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS) reduces mortality rates. Patients admitted to hospitals without revascularization capability have high mortality rates and are not often transferred for ERV.

Methods

Transfer and direct-admit patients with STEMI from the SHOCK Trial and Registry with left ventricular failure (N = 969) were analyzed to determine benefit of ERV in transfer patients.

Results

Transfer patients (46%) were younger and less likely to have prior hypertension, myocardial infarction, and heart failure. They received more aggressive treatment, were revascularized later after CS (median 7.3 vs 3.9 hours, P = .0002), and had similar adjusted inhospital mortality compared with direct-admit patients (55% vs 56%). Inhospital mortality was lower in ERV than no/late revascularization (41% vs 53%, P = .017 for transfer patients; 55% vs 71%, P = .0003 for direct-admit patients). Multiple logistic regression showed that inhospital mortality was associated with age (odds ratio [OR] 1.50 per decade increase, 95% CI 1.31-1.73, P < .0001), mean arterial pressure (OR 0.98 per 1 mm Hg increase, 95% CI 0.97-0.99, P < .0001), fibrinolysis before CS (OR 0.65, 95% CI 0.52-0.96, P = .040), and ERV (OR 0.70, 95% CI 0.52-0.96, P = .028), but not transfer admission (OR 1.23, 95% CI 0.86-1.74, P = .26).

Conclusions

Despite longer time to treatment, transfer patients are a selected population with similar adjusted inhospital mortality and ERV benefit as direct-admit patients. Selected patients with STEMI and CS admitted to hospitals without revascularization capability should be transferred to centers with revascularization capability for immediate angiography.

Section snippets

Study design

This subgroup analysis of the SHOCK Trial and Registry was prespecified in the study protocol. Details about the study design have been published previously.12 In brief, patients developing CS within 36 hours of onset of STEMI were randomized within 12 hours after CS onset to ERV or initial medical stabilization. Patients in the ERV group received PCI or coronary artery bypass graft surgery as soon as possible and within 6 hours of randomization. In the initial medical stabilization group,

Baseline characteristics

Transfer patients were younger and less often had prior hypertension, myocardial infarction, and congestive heart failure than direct-admit patients (Table I). Transfer patients more often had electrocardiographic ST-segment elevation and higher creatine phosphokinase release. Hemodynamic profiles from the time of CS onset were similar in transfer and direct-admit patients except for a faster heart rate in transfer patients. Coronary angiography was performed in 69% of the cohort. In this

Discussion

Our study shows that patients with STEMI and CS in hospitals without revascularization capability transferred to hospitals with revascularization capability represent a selected population13 with more favorable outcomes than patients directly admitted to hospitals with revascularization capability. However, adjusted mortality rates in both transfer and direct-admit patients were similar. Importantly, despite delayed time to treatment in the transfer patients, ERV resulted in a reduction of

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