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Management of cardiogenic shock complicating acute myocardial infarction: towards evidence based medical practice
  1. S G Williams,
  2. D J Wright,
  3. L B Tan
  1. Cardiology Research, Yorkshire Heart Centre, Leeds General Infirmary, Leeds LS1 3EX, UK
  1. Dr Tan

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The treatment of cardiogenic shock is the ultimate challenge of our ability to manage patients presenting with acute myocardial infarction. Despite advances in the treatment of infarcts with thrombolysis, there has been no significant decrease in the incidence of cardiogenic shock, which has remained at 7–10% during the last 20 years.1-5Hospital mortality was over 90% in the 1970s6 and is still high, in the region of 45–80%, in the 1990s.1 ,7-9 Attitudes towards treatment of cardiogenic shock range from resignation, providing supportive measures only, to aggressive intervention. In the era of evidence based medical practice, are there data to support adoption of either extreme of approach?

Registry of cardiogenic shock patients

The largest prospectively identified registry of patients with cardiogenic shock so far analysed is from the GUSTO-I (global utilisation of streptokinase and tissue plasminogen activator for occluded coronary arteries) trial.4 ,8 ,10 Of the 41 021 patients recruited into that study, 7.2% (2972) developed cardiogenic shock, with an overall 30 day mortality of 55%.8 For those undergoing coronary artery bypass grafting (CABG) the 30 day mortality was 29%, and for those having percutaneous transluminal coronary angioplasty (PTCA) it was 22%. On single factor comparison of one year mortality, the hazard ratio (after adjustments for baseline characteristics) for PTCA versus no PTCA was 0.81 (95% confidence interval (CI), 0.71 to 0.94; p < 0.005), suggesting that there may be medium term benefit with the PTCA management strategy. However, patients were not randomly allocated to revascularisation or conservative treatment in that study, and the better PTCA outcome could reflect selection bias. The hazard ratio for CABG versus no CABG was 1.08 (95% CI, 0.89 to 1.30; p = 0.445). It is unclear why the 30 day mortality advantage of CABG was not mirrored at one year.

The SHOCK (should we emergently revascularise …

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