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(Circulation. 1997;96:122-127.)
© 1997 American Heart Association, Inc.
Articles |
Impact of an Aggressive Invasive Catheterization and Revascularization Strategy on Mortality in Patients With Cardiogenic Shock in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) Trial
An Observational Study
From the Division of Cardiovascular Diseases (P.B.B., D.R.H.), Mayo Clinic, Rochester, Minn; Division of Cardiology (A.L.S., R.M.C.), Duke Clinical Research Institute, Durham, NC; Division of Cardiology (E.R.B.), University of Michigan (Ann Arbor); and Department of Cardiology (E.J.T.), Cleveland Clinic, Cleveland, Ohio.
Correspondence to Peter B. Berger, MD, Division of Cardiovascular Disease and Internal Medicine, Mayo Clinic, Rochester, MN 55905. E-mail berger.peter{at}mayo.edu
Background Although retrospective analyses have revealed an association between survival and coronary angiography and angioplasty in patients with acute myocardial infarction complicated by cardiogenic shock, the degree to which bias in the selection of patients to undergo these procedures contributes to this observation remains unclear.
Methods and Results We studied 2200 patients in the Global
Utilization of Streptokinase and Tissue Plasminogen
Activator for Occluded Coronary Arteries (GUSTO-I)
trial with acute myocardial infarction complicated by cardiogenic shock
(systolic blood pressure <90 mm Hg for 
1 hour) who
survived 1 hour after the onset of shock to determine the influence
of an aggressive strategy of early angiography (within 24 hours of
shock onset) and coronary angioplasty or bypass surgery, if
appropriate, on survival. Revascularization was not
protocol mandated but was selected by the attending physicians. Shock
was present on admission in 11% and developed after admission in
89% of shock patients. The 30-day mortality was 38% in the 406
patients who underwent early angiography and were referred within 24
hours for angioplasty (n=175), bypass surgery (n=36), angioplasty and
bypass surgery (n=22), or neither (late or no
revascularization, n=173) compared with 62% in the
1794 patients who did not (P=.0001). However, there were
important differences in the baseline characteristics of the two
groups, including younger age (63 versus 68 years, P=.0001),
less prior infarction (19% versus 27%, P=.001), and a
shorter time to thrombolytic therapy (2.9 versus 3.2
hours, P=.0001) in patients treated with an aggressive
strategy. Using multivariate logistic regression
analysis to adjust for differences in baseline characteristics,
an aggressive strategy was independently associated with reduced 30-day
mortality (odds ratio, 0.43 [confidence interval, 0.34 to 0.54],
P=.0001).
Conclusions An aggressive strategy of early angiography (and revascularization when appropriate) is associated with a reduction in mortality in patients with acute myocardial infarction and cardiogenic shock who receive thrombolytic therapy.
Key Words: angiography • angioplasty • infarction • reperfusion • shock
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