Advertisement

Mostly Early Invasive Management May Improve Outcomes in Patients with Myocardial Infarction and Cardiogenic Shock

      To the Editor:
      Dr Bangalore et al
      • Bangalore S.
      • Gupta N.
      • Guo Y.
      • et al.
      Outcomes with invasive versus conservative management of cardiogenic shock complicating acute myocardial infarction.
      reported improved in-hospital mortality when invasive management (coronary angiography, percutaneous coronary intervention, or coronary artery bypass graft) was performed in patients hospitalized for cardiogenic shock due to myocardial infarction. All subgroups benefited from this invasive strategy. However, as acknowledged, propensity analysis did not account for unmeasured confounders, for example, do not reanimate orders, pulmonary hypertension, and acute renal failure.
      • Champion S.
      • Gaüzère B.
      • Vandroux D.
      • et al.
      Dobutamine infusion and absence of pulmonary hypertension are associated with decreased mortality in a cohort of 249 patients with cardiogenic shock.
      The last situation may be dramatic and prevent injection of iodine products.
      Furthermore, most patients may have died before being stabilized enough to undergo invasive investigations.
      • Dzavik V.
      • Sleeper L.A.
      • Cocke T.P.
      • et al.
      Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry.
      Although percutaneous coronary intervention is feasible and may be lifesaving under assistance such as extracorporeal membrane oxygenation, some physicians may deny aggressive management or dangerous transportation for patients with such dismal prognosis. Thus, drawing Kaplan-Meier curves would be of interest to address this issue, with focus on the very first hours.
      In this regard, it is noticeable that patients underwent invasive management in the late stage of their disease; 17% and 44% of patients underwent percutaneous coronary intervention and coronary artery bypass grafting, respectively, after 24 hours.
      • Bangalore S.
      • Gupta N.
      • Guo Y.
      • et al.
      Outcomes with invasive versus conservative management of cardiogenic shock complicating acute myocardial infarction.
      Patients with invasive management before or after 24 hours had a similar improved outcome compared with patients with conservative management. This may be interpreted as selection bias, because patients who survived initial cardiogenic shock may have been treated by revascularization, as acknowledged. In the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock trial, revascularization could be performed after 48 hours in the initial medical stabilization group with worse prognosis. Early revascularization was associated with improved outcome compared with late (>18 hours) or no revascularization in the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock registry.
      • Dzavik V.
      • Sleeper L.A.
      • Cocke T.P.
      • et al.
      Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry.
      The exact time window for revascularization is not precisely known. Basically, early invasive management should be proposed to patients with myocardial infarction and cardiogenic shock.
      Finally, the method of revascularization in patients with cardiogenic shock is not well known because they were excluded from most of the trials. The choice between multivessel percutaneous coronary intervention and coronary artery bypass grafting in such patients with myocardial infarction and cardiogenic shock is still a matter of debate and should be made by the heart team on an individual basis, with particular interest on the time window and immediate (and late) prognosis improvement.
      • Champion S.
      • Gaüzère B.A.
      • Lefort Y.
      Drug-eluting stents should not be used in ST-elevated myocardial infarction with cardiogenic shock.
      Percutaneous coronary intervention can be performed promptly at the time of first coronary angiography. It is the most common way of revascularization. Only 4% of patients with myocardial infarction and cardiogenic shock underwent urgent coronary artery bypass grafting in Germany, much less than the 22% reported by Bangalore et al.
      • Bangalore S.
      • Gupta N.
      • Guo Y.
      • et al.
      Outcomes with invasive versus conservative management of cardiogenic shock complicating acute myocardial infarction.

      References

        • Bangalore S.
        • Gupta N.
        • Guo Y.
        • et al.
        Outcomes with invasive versus conservative management of cardiogenic shock complicating acute myocardial infarction.
        Am J Med. 2015; 128: 601-608
        • Champion S.
        • Gaüzère B.
        • Vandroux D.
        • et al.
        Dobutamine infusion and absence of pulmonary hypertension are associated with decreased mortality in a cohort of 249 patients with cardiogenic shock.
        Health. 2014; 6: 2408-2415
        • Dzavik V.
        • Sleeper L.A.
        • Cocke T.P.
        • et al.
        Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry.
        Eur Heart J. 2003; 24: 828-837
        • Champion S.
        • Gaüzère B.A.
        • Lefort Y.
        Drug-eluting stents should not be used in ST-elevated myocardial infarction with cardiogenic shock.
        Arch Intern Med. 2012; 172: 1613-1614

      Linked Article

      • Outcomes with Invasive vs Conservative Management of Cardiogenic Shock Complicating Acute Myocardial Infarction
        The American Journal of MedicineVol. 128Issue 6
        • Preview
          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.
        • Full-Text
        • PDF
      • The Reply
        The American Journal of MedicineVol. 128Issue 8
        • Preview
          Champion contends that early invasive management may improve outcomes in patients with myocardial infarction and cardiogenic shock. We fully agree. The SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK (SHOCK) trial compared an invasive strategy of emergent revascularization versus a conservative strategy of initial medical stabilization.1,2 In the conservative strategy, 66.7% of patients received coronary angiography with 25.3% of patients receiving angioplasty or coronary artery bypass graft surgery with a median time to revascularization from randomization of 102.8 hours.
        • Full-Text
        • PDF