November 16, 1999
View Full PaperCardiogenic Shock in Patients With Acute Ischemic Syndromes With and Without ST-Segment Elevation
Key Result
Non-ST-segment elevation acute ischemic syndromes were associated with a lower incidence of cardiogenic shock compared to ST-segment elevation (2.5% vs 4.2%; OR 0.581; 95% CI 0.472-0.715; P<0.001).
Study Design
Type
Observational (n=12,084)
Multicenter
Yes
Structured PICO
Does the incidence and mortality of cardiogenic shock differ between patients with and without ST-segment elevation acute ischemic syndromes?
P
Population
12,084 patients with acute ischemic syndromes who did not present with cardiogenic shock (4,092 with ST-segment elevation, 7,991 without ST-segment elevation) from the GUSTO-IIb trial.
I
Intervention
Acute ischemic syndromes with ST-segment elevation
C
Comparator
Acute ischemic syndromes without ST-segment elevation
O
Outcome
Incidence of cardiogenic shock developing after enrollmenthard clinical
Cardiogenic shock occurs in both STEMI and NSTEMI patients, with a higher incidence in STEMI but similarly high mortality in both groups once it develops.
Main Result
Effect estimate: OR 0.581 (95% CI 0.472 to 0.715)
Absolute Event Rate: 2.5% vs 4.2%
p-value: p=<0.001
Abstract
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.