Context: Cardiogenic shock (CS) is the leading cause of death for patients hospitalized with acute myocardial infarction (AMI). Objective: To assess the effect of early revascularization (ERV) on 1-year survival for patients with AMI complicated by CS. Design: The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) Trail, an unblinded, randomized controlled trial from April 1993 through November 1998. Setting: Thirty-six referral centers with angioplasty and cardiac surgery facilities. Patients: Three hundred two patients with AMI and CS due to predominant left: ventricular failure who met specified clinical and hemodynamic criteria. Interventions: Patients were randomly assigned to an initial medical stabilization (IMS; n=150) group, which included thrombolysis (63% of patients), intra-aortic balloon counterpulsation (86%), and subsequent revascularization (25%), or to an ERV group (n=152), which mandated revascularization within 6 hours of randomization and included angioplasty (55%) and coronary artery bypass graft surgery (38%). Main Outcome Measures: All-cause mortality and functional status at 1 year, compared between the ERV and IMS groups. Results: One-year survival was 46.7% for patients in the ERV group compared with 33.6% in the IMS group (absolute difference in survival, 13.2%; 95% confidence interval [CI], 2.2%-24.1%; P<.03; relative risk for death, 0.72; 95% CI, 0.54-0.95). Of the 10 prespecified subgroup analyses, only age (<75 vs ≥ 75 years) interacted significantly (P<.03) with treatment in that treatment benefit was apparent only for patients younger than 75 years (51.6% survival in ERV group vs 33.3% in IMS group). Eighty-three percent of 1-year survivors (85% of ERV group and 80% of IMS group) were in New York Heart Association class I or II. Conclusions: For patients with AMI complicated by CS, ERV resulted in improved 1-year survival. We recommend rapid transfer of patients with AMI complicated by CS, particularly those younger than 75 years, to medical centers capable of providing early angiography and revascularization procedures.
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