Faculty Collaboration Database

Outcomes with invasive vs conservative management of cardiogenic shock complicating acute myocardial infarction. Am J Med 2015 Jun;128(6):601-8

Date

01/03/2015

Pubmed ID

25554376

DOI

10.1016/j.amjmed.2014.12.009

Scopus ID

2-s2.0-84930380869 (requires institutional sign-in at Scopus site)   48 Citations

Abstract

BACKGROUND: In the SHOCK trial, an invasive strategy of early revascularization was associated with a significant mortality benefit at 6 months when compared with initial stabilization in patients with cardiogenic shock complicating acute myocardial infarction. Our objectives were to evaluate the data on real-world practice and outcomes of invasive vs conservative management in patients with cardiogenic shock.

METHODS: We analyzed data from the Nationwide Inpatient Sample from 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery) vs conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality.

RESULTS: We identified 60,833 patients with cardiogenic shock, of which 20,644 patients (10,322 in each group) with similar propensity scores, including 11,004 elderly patients (≥75 years), were in the final analysis. Patients who underwent invasive management had 59% lower odds of in-hospital mortality (37.7% vs 59.7%; odds ratio [OR] 0.41; 95% confidence interval [CI], 0.39-0.43; P < .0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (≥75 years) (44.0% vs 63.6%; OR 0.45; 95% CI, 0.42-0.49; P < .0001) and those younger than 75 years (30.6% vs 55.1%; OR 0.36; 95% CI, 0.33-0.39; P < .0001), although the magnitude of risk reduction differed (Pinteraction < .0001).

CONCLUSIONS: In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup.

Author List

Bangalore S, Gupta N, Guo Y, Lala A, Balsam L, Roswell RO, Reyentovich A, Hochman JS

MESH terms used to index this publication - Major topics in bold

Aged
Cardiac Catheterization
Coronary Artery Bypass
Female
Hospital Mortality
Humans
Male
Middle Aged
Myocardial Infarction
Percutaneous Coronary Intervention
Shock, Cardiogenic
Treatment Outcome