CARDIOGENIC SHOCK
Cardiogenic Shock: A Summarv of the
Randomized SHOCK Trial
Cardwgenic shck is the most c o m m cause of deathfor pa-
tients h s p l i z e d with acute myocardial infarction. The
Should We Emergently Revasculariz Occluded Cmmulries
for Cardwgenic Shock (SHOCK) hialrandomly asszgned
302patients with p e h i n a n t l.Jt ventricular failurefollow-
ing an acute myocardial infarctiun to a strategy of emergency
rmascularhtim or initial m e d i d stabiliultion. Emergency
rmascularhtim by either c o r m r y artery bypass graftzng or
angwphty was required within 6 hours of randomization.
Patients assigned to initial medical stabdimtian could under-
go delayed rmasculahtion at a minimum of 54 hours post-
randomization. Thepwnury end point of the study was 30-
day all-cause mortalq. Overall suruival at 30 days did not
d@er significantly between the emergency rmasculariiultion
and initial medical stabilization groups (53%us. 44%;
p=0.109). Howmer, at the 6- and 12-monthfollow-up, there
was a signajikant suruival benefit with early rmasculahtion
(50% us. 37%; p=0.027 and 47% us. 34%; p=0.025, re-
spectively). The benefit appeared to be greatat for t h s e less
than 75years of age, with 20 lives saved at 6 months per 100
patients treated. According to the results of the SHOCK trial,
the American College of CardiologylAmericanHeart Associa-
tion pia'elimsfor myocardial infarction now recommend
emergency revascularhtimfor patients younger than 75
years with cardwgenic shock. (CHF. 2003;9:35-39,46)
W O O 3 CHF, Inc.
Venu Menon, MD; Rupert Fincke, M D
From the Division of Cardiology, St. LukekRoosevelt
Hospital Center, Columbia University, New York, N Y
Address for correspondence:
Venu Menon, MD, Assistant Director of Cardiac Research,
Division of Cardiology, St. Luke's-Roosmelt Hospital
Center, 1111Amsterdam Avenue, New York, NY 10025
E-mail: vmenon@slrhc.org
Manuscript received December 21, 2000;
accepted January 4, 2001
CHF JANUARY/FEBRUARY 2003 35
Cardiogenic shock (CS) is the most common cause of
death for patients hospitalized with acute myocardial
infarction (MI).l?*Although the overall incidence re-
mains unchanged, mortality rates from this clinical
entity appear to be declining.3.4 This favorable trend
has been associated with increasing utilization of
reperfusion therapy, revascularization, and hemody-
namic support with intra-aortic balloon pumping
(IABP).The superior outcome among CS patients in
the United States over their non-American counter-
parts has also been attributed to this aggressive ap-
proach.5 Despite this positive relationship, these ob-
servations do not directly prove cause and effect.
Revascularization in these reports was not protocol-
mandated, but driven by individual clinical judg-
ment. Sophisticated post-hoc statistical adjustment
cannot adjust for unmeasured variables and this sets
up the possibility of selection bias.6
Designing a randomized, controlled trial in the set-
ting of CS complicating acute MI is limited by the
need for expedient therapy, the rapid demise of criti-
cally ill patients, and physician bias. Prospective data
in this area were, however, clearly warranted. The Na-
tional Heart, Lung, and Blood Institute supported the
SHOCK (Should We Emergently Revascularize Oc-
cluded Coronaries for Cardiogenic Shock) trial7 and
@)MASH(Swiss) Multicenter Trial of Angioplasty for
Shock,E which were designed to fill this void. Both tri-
als examined the benefit of early revascularization in
the setting of CS. Regrettably, @)MASHwas terminat-
ed prematurely due to insuf€icient patient enrollment.
The SHOCK trial was successfully completed and en-
rollment was stopped in November, 1998. In this re-
view, we briefly describe the SHOCK trial design and
highlight salient trial findings.
Trial Design
The hypothesis and design of the SHOCK trial have
been previously published.9 Figure 1 outlines the trial
design. The trial aimed to test the superiority of a
strategy of early committed revascularization (ERV)
over that of initial medical stabilization (IMS). Pa-
tients assigned to the IMS arm could undergo delayed
revascularization at a minimum of 54 hours post-ran-
domization, as per the decision of the local site inves-
tigator. For patients to qualify, CS had to occur within
36 CARDIOGENIC SHOCK
Emergency Initial medical
revascularization stabilization
Figure 1. Design of the Should We Emergently Revascular-
ize Occluded Coronaries for Cardiogenic Shock (SHOCK)
Trial and suggested treatment according to group assign-
ment. Revascularization in the initial medical stabilization
arm was at least 48 hours later than in the emergency re-
vascularization arm.
PTCA =percutaneous transluminal coronary angioplasty;
CABG=coronary artery bypass grafting; IABP=intra-aor-
tic balloon pumping
36 hours of the index MI, and randomization had to
occur within 12 hours of shock diagnosis. The ERV
arm required angioplasty or bypass surgery as soon as
possible and within 6 hours of randomization. IABP
counterpulsation was strongly recommended for both
treatment arms.
Standard clinical and hemodynamic criteria were
applied for the definition of shock, as outlined in the
Table. Only patients with CS arising from predomi-
nant left ventricular (LV) failure following MI with ST
elevation or new left bundle branch block were in-
cluded. Exclusion criteria included ventricular septal
rupture, cardiac tamponade, severe valvular disease,
isolated right ventricular CS, known dilated car-
diomyopathy, shock from other causes (e.g., sepsis,
hypovolemia), prior severe systemic illness, rehsal by
the patient’s physician, and failure to provide in-
_ -
Table. Definition of Shock Clinical and Hemody-
namic Criteria
Cardiogenic shock: clinical criteria
Systolic blood pressure <90 mm Hg for 30 min-
utes before inotropes/vasopressors, or vasopres-
sors or IABP are required to maintain systolic
blood pressure 190 mm Hg
Evidence of decreased organ perfusion
Heart rate 260 beats per minute (including
paced rhythms)
Cardiogenic shock: hemodynamic criteria
PCWP 215 mm Hg
Cardiac index 22.2 Ijmin/mz
IABP= intra-aorticballoon pumping; PCWP= pul-
monary capillary wedge pressure
CHF JANUARY/FEBRUARY2003
formed consent. All participating sites had institu-
tional review board or ethics committee approval. Pa-
tients ineligible for the trial were enrolled in a
prospective SHOCK registry.
The primary end point of the study, 30-day all-cause
mortality, was monitored by the Data and Safety Moni-
toring Board. The final sample size of 302 patients had
88%-89% power to detect an absolute 20% mortality
difference between the two treatment strategies.
Timing of Shock
CS may present as an early complication following ST
elevation and MI. In the SHOCK trial, the median
time from MI to shock onset was 5.0 hours (25th to
75th percentile, 2.2-12.0 hours) in the ERV group
and 6.2 hours (2.4-15.5 hours) in the IMS group.
Similarly, in the SHOCK registry it was 7.0 hours
(1.8-2.2 hours). This is in contrast to the Global Uti-
lization of Streptokinase and Tissue Plasminogen Ac-
tivator for Occluded Coronary Arteries (GUSTO)-1
thrombolytic megatrial, in which a majority of pa-
tients developed CS later, after randomization.1 Al-
though GUSTO-1 did not exclude patients with CS,
this disparity in timing reflects the selective nature of
patients entering thrombolytic trials. Site investiga-
tors in thrombolytic trials may not consider patients
who are moribund at admission or at high risk for
early death. Consequently, the recorded timing of
shock may be skewed in these studies.
Etiology of Shock
The etiology of shock was aggressively pursued in the
SHOCK trial and registry. While the trial enrolled
patients with predominant LV failure, other causes of
CS were included in the registry10 (predominant LV
failure, 74.3%; acute, severe mitral regurgitation,
8.3%; ventricular septal rupture, 4.6%; “isolated”
right ventricular shock, 3.4%; tamponade rupture,
1.7%; other, 8%).Contrary to classical teaching, me-
chanical complications occurred early post-MI and
the median time from MI to interventricular septal
rupture (VSR) in this setting was 16 hours.’’ Reasons
for this discrepancy deserve mention. Classical teach-
ing was largely based on surgical series that reported
mainly on rupture patients surviving to the operating
room.12113 Further, the mean time to VSR was fre-
quently used. As VSR can occur both early and late
post-MI, the true timing may have been misrepre-
sented in these skewed observations. Overall outcome
for patients with diagnosed VSR in the setting of CS
was dismal: of the 55 patients registered, only seven
survived. Thirty-one patients underwent ventricular
septal repair, but only six survived. Consequently, all
CARDIOGENIC SHOCK
patients with VSR complicating acute MI should be
immediately referred for surgery. The onset of hemo-
dynamic instability in this population is unpre-
dictable and associated with a poor prognosis.
Location of MI. By virtue of infarct size, CS is more
common after anterior MI (60% in SHOCK).7 How-
ever, a sizable minority of subjects enrolled in the
SHOCK trial had an index inferior wall MI. In the
SHOCK registry, more than one third of patients
with inferior MI had either a prior MI or a mechani-
cal cause of shock.10 Patients with inferior MI and CS
need to be carefully evaluated. An early screening
echocardiogram in this group appears to be of great
clinical utility. The echo image quantifies the area of
LV infarction and the compensatory response of the
remote myocardium. It confirms the integrity of car-
diac anatomy by screening for ventricular or free wall
rupture, tamponade, and papillary muscle rupture,
all of which necessitate emergent surgery. Finally, the
functional status of the right ventricle can be evaluat-
ed. In the setting of severe right-sided dysfunction, ia-
trogenic fluid overload may cause a significant septa1
shift, impair LV filling, and cause right-to-left shunt-
ing via a patent foramen ovale.
Coronary Anatomy. Subjects presenting with CS have
left main (20% in SHOCK) or triple-vessel disease
(64%) and severely reduced LV function on cardiac
catheterization (mean ejection fraction, 31%).7This is in
contrast to the preserved LV function (mean ejection
fraction, 58%+ 15% on 90-minute ventriculograph in
GUSTO-1)14 and single-vesseldisease (52%in GUSTO-
1) seen with the universe of ST elevation MI.15 Conse-
quently, any revascularization strategy in the setting of
CS must include provisions for emergent coronary
artery bypass surgery. An isolated percutaneous inter-
vention approach will be hampered by the limited suc-
:1 p=.109 p= .027 p= .025
Bo 1 53
30-Day 6-Month 12Month
(302) (302) (301)
Figure 2. Overall survival at 1, 6, and 12 months of fol-
low-up.
ER V-emergency revascularization; IMS =initial med-
ical stabilization
CHF JANUARY/FEBRUARY 2003 37
cess with unprotected left main stenting as well as mul-
tivessel angioplasty in this critical setting. Limited ex-
pertise also limits the performance of multivessel angio-
plasty under percutaneous bypass.16 A strategy of per-
cutaneous transluminal coronary angioplasty (PTCA)of
the infarct related artery followed by coronary artery
bypass grafting (CABG) may be useful in certain
anatomic subsets but remains formally untested.
Salient Findings
Emergency Revascularization vs. Initial Medical
Stabilization. The superiority of an ERV over an IMS
strategy did not reach statistical significance at 30 days
in the SHOCK trial (Figure 2). This was because the
9% absolute difference in 30-day survival seen with
ERV was less than the expected 20% benefit predicted
at the time of the trial design. However, the potential
for nine absolute lives saved per 100 treated appears to
support this approach. A larger sample size would be
required to formally prove this, and future conduct of
randomized trials appears unlikely. This ERV strategy
is further supported by long-term follow-up survival
data. ERV was clearly superior to IMS at 6 months,
with 13 lives saved per 100 patients treated. This bene-
ficial effect was stable at 1 year of follow-up (Figure 2).
The increasing survival benefit with ERV between 1
and 6 months is in contradistinction to the parallel
lines beyond 30 days for thrombolysis over placebo17
and the decreasing benefit of primary PTCA over
thrombolysis at 6 months in patients with acute MI and
no shock.18JgIt is similar to the divergence in the long-
,
term survival curves for patients with normal coronary
flow (TIMI 111) and those with abnormal flow (TIMI
0-11) in the GUSTO trial.20
Who Benefits? Only 15% of hospitals in the United
States have the capability to perform PTCA.21 Conse-
quently, adopting a universal strategy of ERV in the
setting of CS is difficult. Our experience in the
80 peo.01 p<o.o1
70 1
60
E 50
40 438 , 358 ,
8! 30
20 Treatment x Age group
10 Interaction p-valuer:
30-day: 0.012
0
6-month: 0.003
30-Day 6-Month
(N=246) (N=244)
Figure 3. Survival for patients less than 75 years of age.
ERV=emergency revascularization; IMS =initial med-
ical stabilization
38 CARDIOGENIC SHOCK
SHOCK study indicates that benefit with an ERV
strategy is greatest for those less than 75 years of age,
with 20 lives saved at 6 months per 100 patients treat-
ed (Figure 3). On the basis of this evidence, we advo-
cate emergent transfer to tertiary facilities for this
younger subset of patients. The recently updated
American College of Cardiology/American Heart As-
sociation (ACC/AHA) guidelines adopt a similar
stance, based on current evidence.22 When transfer is
unfeasible and in those greater than 75 years of age,
an IMS approach similar to that in the SHOCK trial
should be advocated. In the trial, the IMS strategy,
which included thrombolysis (63%), IABP support
(86%),and physician-directed delayed revasculariza-
tion (25%),resulted in lower mortality rates than his-
torical controls.3 This IMS strategy proved equivalent
to an ERV strategy among the elderly and seems to be
an acceptable initial strategy. Alternatively, selective
use of an ERV strategy in patients over 75 years of
age was associated with an excellent outcome in the
SHOCK registry.
Mode of Revascularization. The mode of revascu-
larization in the setting of CS is best guided by coro-
nary anatomy, and both FTCA and CABG play pivotal
roles. In the SHOCK trial, percutaneous intervention
was performed in 55% (n=83/152) of patients in the
ERV group. The 77% procedural success with percuta-
neous intervention in this setting is consistent with that
of earlier reports 23 and lower than that reported with
primary angioplasty in the setting of all ST elevation
MIs.3,24,25This is presumably due to a combination of
diffuse multivessel disease, large thrombus burden,
and coronary hypoperfision. Furthermore, the no re-
flow phenomenon may occur more often in CS.26 Suc-
cessful percutaneous intervention in this setting is
clearly associated with a superior outcome and proce-
dural failure is associated with increased 30-day mor-
tality (38% ~ ~ 7 9 p=0.003).
%; Overall mortality with
percutaneous intervention in this randomized trial was
40% (n= 105).7 This is similar to the 44% cumulative
mortality (n= 1167) reported in 24 previous trials.23
The use of coronary stents and platelet glycoprotein
IIb/IIIa receptor antagonists has revolutionized percu-
taneous intervention in the past 5 years. A number of
single-center experiences in the setting of shock have
been reported.27-30 In SHOCK, stent and IIb/IIIa re-
ceptor antagonist use increased from 0% in 1993-1994
to 74% and 59% in 1997 and 1998, respectively. No in-
creased survival benefit was apparent in these small
subsets of patients.7
The feasibility of CABG in the setting of CS has been
previously reported.23 In the SHOCK trial, CABG was
recommended for severe triple-vessel coronary artery
disease, left main artery disease, and failed percuta-
CHF JANUARY/FEBRUARY 2003
neous intervention.9Thii-eight percent (n= 57/152) of
patients in the ERV group underwent this procedure.
Despite more extensive coronary disease, mortality
with CABG was similar to that with percutaneous inter-
vention in both the SHOCK trial (41% vs. 40% for pa-
tients assigned to ERV or IMS)7 and registry (28%vs.
46%).10 The ability to perform complete revasculariza-
tion and the myocardial protection offered by car-
diopulmonary bypass may have contributed to this fa-
vorable outcome. CABG appears to be an excellent
revascularization option in this scenario.
Role of Intra-Aortic Balloon Pumping. IABP
support was strongly advocated in both arms of the
SHOCK trial and played an integral role in the med-
ical stabilization arm. The overall utilization of IABP
in this group was 86%,7considerably higher than the
24% and 25% balloon pump utilization rates seen
with shock in GUSTO-11 and GUSTO-III,31 respec-
tively. Although conclusions are speculative, IABP
may have been largely responsible for the favorable
historical outcome seen in this group.3 This is be-
cause there is experimental evidence suggesting en-
hanced thrombolytic efficacy in this setting.32 This
positive experience is also supported by the large
National Registry of Myocardial Infarction (NRMI)
database33 and the randomized, multicenter Throm-
bolysis and Counterpulsation to Improve Cardio-
genic Shock Survival (TACTICS) trial.34 TACTICS
was terminated prematurely because of insufficient
patient recruitment, but the results suggest a 9% ab-
solute reduction of mortality at 6 months (p=0.23)
with the combination of thrombolysis and IABP. Ac-
cording to these findings, IABP should be used in
the management of CS. Unfortunately, IABP use is
uncommon in community hospitals. Reasons for this
may include lack of physician expertise and cost.
Physician education and regional expertise are po-
tential solutions. Results of the SHOCK and TAC-
TICS trials may help to rectify this problem.
Conclusion
Although there was no benefit at 30 days, among
patients in CS due to LV dysfunction associated
with an ST elevation MI, a strategy of ERV was su-
perior to IMS at 6 and 12 months of follow-up. Pa-
tients younger than 75 years of age benefited most,
with 20 lives saved at 6 months per 100 patients
treated. According to the results of the SHOCK
trial, ERV is now a class I indication for this patient
population in the ACC/AHA myocardical infarction
guidelines.22 Mortality with CABG was similar to
that with percutaneous intervention in this high-
risk population.
CARDIOGENIC SHOCK
Outlook
The risk of developing CS increases with age.1,3>35,36
Age is also a potent predictor of mortality following
acute MI.37,38 Consequently, although the age-ad-
justed case fatality rate following acute MI has fall-
en dramatically over the past three decades, the in-
cidence of MI, incidence of CS, and the unadjusted
mortality rate following MI have remained relative-
ly constant. Present demographics will ensure an
increasing baseline risk in future MI populations.
The economic and health care demands arising
from this are staggering. Despite the advances in
primary prevention, research in CS should remain
a high priority. Novel modalities to preserve is-
chemic myocardium need to be studied. One ap-
proach that may warrant investigation in CS is the
use of glucose-insulin-potassiuminfusions.39 In the
interim, our clinical experiences in the SHOCK
trial will help guide present available therapy.
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continued on page 46