Early revascularization in acute myocardial infarction complicated by cardiogenic shock

Background The leading cause of death in patients hospitalized for acute my ocardial infarction is cardiogenic shock. We conducted a randomized trial t o evaluate early revascularization in patients with cardiogenic shock. Methods Patients with shock due to left ventricular failure complicating my ocardial infarction were randomly assigned to emergency revascularization ( 152 patients) or initial medical stabilization (150 patients). Revasculariz ation was accomplished by either coronary-artery bypass grafting or angiopl asty. Intraaortic balloon counterpulsation was performed in 86 percent of t he patients in both groups. The primary end point was mortality from all ca uses at 30 days. Six-month survival was a secondary end point. Results The mean (+/-SD) age of the patients was 66+/-10 years, 32 percent were women, and 55 percent had been transferred from other hospitals. The m edian time to the onset of shock was 5.6 hours after infarction, and most i nfarcts were anterior in location. Ninety-seven percent of the patients ass igned to revascularization underwent early coronary angiography, and 87 per cent underwent revascularization; only 2.7 percent of the patients assigned to medical therapy crossed over to early revascularization without clinica l indication. Overall mortality at 30 days did not differ significantly bet ween the revascularization and medical-therapy groups (46.7 percent and 56. 0 percent, respectively; difference, -9.3 percent; 95 percent confidence in terval for the difference, -20.5 to 1.9 percent; P = 0.11). Six-month morta lity was lower in the revascularization group than in the medical-therapy g roup (50.3 percent vs. 63.1 percent, P=0.027). Conclusions In patients with cardiogenic shock, emergency revascularization did not significantly reduce overall mortality at 30 days. However, after six months there was a significant survival benefit. Early revascularizatio n should be strongly considered for patients with acute myocardial infarcti on complicated by cardiogenic shock. (N Engl J Med 1999;341:625-34.) (C) 19 99, Massachusetts Medical Society.