Outcomes with invasive vs conservative management of cardiogenic shock complicating acute myocardial infarction

Sripal Bangalore, Navdeep Gupta, Yu Guo, Anuradha Lala, Leora Balsam, Robert O. Roswell, Alex Reyentovich, Judith S. Hochman

Research output: Contribution to journalArticlepeer-review

44 Scopus citations

Abstract

Background 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. Methods We analyzed data from the Nationwide Inpatient Sample from 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery) vs conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality. Results We identified 60,833 patients with cardiogenic shock, of which 20,644 patients (10,322 in each group) with similar propensity scores, including 11,004 elderly patients (≥75 years), were in the final analysis. Patients who underwent invasive management had 59% lower odds of in-hospital mortality (37.7% vs 59.7%; odds ratio [OR] 0.41; 95% confidence interval [CI], 0.39-0.43; P <.0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (≥75 years) (44.0% vs 63.6%; OR 0.45; 95% CI, 0.42-0.49; P <.0001) and those younger than 75 years (30.6% vs 55.1%; OR 0.36; 95% CI, 0.33-0.39; P <.0001), although the magnitude of risk reduction differed (Pinteraction <.0001). Conclusions In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup.

Original languageEnglish
Pages (from-to)601-608
Number of pages8
JournalAmerican Journal of Medicine
Volume128
Issue number6
DOIs
StatePublished - 1 Jun 2015
Externally publishedYes

Keywords

  • Cardiogenic
  • Conservative
  • Invasive
  • Shock

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