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(Circulation. 1999;100:2067-2073.)
© 1999 American Heart Association, Inc.

Clinical Investigation and Reports

Cardiogenic Shock in Patients With Acute Ischemic Syndromes With and Without ST-Segment Elevation

David R. Holmes, Jr, MD; Peter B. Berger, MD; Judith S. Hochman, MD; Christopher B. Granger, MD; Trevor D. Thompson, BS; Robert M. Califf, MD; Alec Vahanian, MD; Eric R. Bates, MD; Eric J. Topol, MD

From the Mayo Clinic and Foundation, Rochester, Minn (D.R.H., P.B.B.); Columbia University/St Luke’s/Roosevelt Hospital, New York, NY (J.S.H.); Duke Clinical Research Institute, Durham, NC (C.B.G., R.M.C.); Emory University, Atlanta, Ga (T.D.T.); Hospital Tenon, Paris, France (A.V.); University of Michigan Medical Center, Ann Arbor (E.R.B.); and Cleveland Clinic Foundation, Cleveland, Ohio (E.J.T.).

Correspondence to David R. Holmes, Jr, MD, Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail dholmes{at}mayo.edu

Background—Cardiogenic shock is usually considered a sequela of ST-segment elevation myocardial infarction. There are limited prospective data on the incidence and significance of shock in non-ST-segment elevation patients. This study assessed the incidence and outcomes of cardiogenic shock developing after enrollment among patients with and without ST-segment elevation in the Global Use of Strategies To Open Occluded Coronary Arteries (GUSTO)-IIb trial.

Methods and Results—Among 12 084 patients in GUSTO-IIb who did not present with cardiogenic shock, 4092 (34%) had and 7991 (66%) did not have ST-segment elevation on the enrollment ECG. Cardiogenic shock developed in 4.2% of ST-segment elevation patients compared with 2.5% of patients without ST-segment elevation (odds ratio, 0.581; 95% CI, 0.472 to 0.715; P<0.001). Shock developed significantly later among patients without ST-segment elevation. There were significant differences in baseline characteristics between shock patients with and without ST-segment elevation: Patients without ST-segment elevation were older, more frequently had diabetes mellitus and 3-vessel disease, but had less TIMI grade 0 flow at angiography. Regardless of the initial ECG, mortality was high: 63% among patients with ST-segment elevation and 73% in those without ST-segment elevation.

Conclusions—Cardiogenic shock occurs in the setting of acute ischemic syndromes regardless of whether ST-segment elevation is present. The incidence, patient characteristics, timing, clinical course, and angiographic findings differ between the 2 groups. Mortality from cardiogenic shock is similarly high among patients with and without ST-segment elevation.

Key Words: shock • myocardial infarction • mortality • acute coronary syndromes • unstable angina

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