A randomized evaluation of early revascularization to treat shock complicating acute myocardial infarction - The (Swiss) Multicenter Trial of Angioplasty for Shock - (S)MASH

Aim To test whether emergency revascularization improves survival in patien ts with acute myocardial infarction and shock. Methods and Results Patients with acute myocardial infarction and early sho ck were randomized either to undergo emergency angiography, followed immedi ately by revascularization when indicated, or to receive initial medical ma nagement. In five of the nine participating centres, patients with shock bu t not randomized were entered in a registry. Only 55 patients could be rand omized. Of the 32 patients in the invasive group, 30 (94%) underwent early angiography, 27 (84%) PTCA, and one (4%) CABG. Twenty-two (69%) died within 30 days in the invasive group vs 18/23 (78%) in the medically managed grou p (ns, RR=0.88, 95% confidence interval 0.6-1.2). Among the registry patien ts, 24/51 were excluded from randomization solely because of patient or phy sician preference for the invasive approach: 23 (96%) of them underwent eme rgency angiography, 21 (88%) PTCA, and 12 (50%) died within 30 days. Among the remaining registry patients (n=27) only nine (33%) underwent early angi ography, nine (33%) PTCA and 20 (74%) died. Conclusion We failed to demonstrate that emergency PTCA significantly impro ves survival in patients with acute myocardial infarction and early cardiog enic shock. Because the study was stopped prematurely, due to an insufficie nt patient inclusion rate, a clinically meaningful benefit of early reperfu sion may have been missed.