Cardiogenic shock complicating acute myocardial infarction: Predictors of death,☆☆,

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Abstract

Background Current knowledge of predictors of death among patients with cardiogenic shock complicating myocardial infarction is limited. We aimed to develop a risk assessment prognostic algorithm of 30-day mortality, including clinical and hemodynamic data prospectively collected among patients with cardiogenic shock in the 41,021-patient Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial. Methods We used logistic regression modeling techniques to evaluate the relations between demographic, clinical, and hemodynamic characteristics and 30-day mortality rate for the entire shock population (n = 2968) and for patients who underwent right-heart catheterization (n = 995). Results The odds (95% confidence interval) of dying were 1.49 times higher (1.27-1.74) for patients 10 years older and 1.70 times higher (1.19-2.44) for patients with prior infarction. Findings derived from physical examination, such as altered sensorium and cold, clammy skin, were important independent predictors of prognosis (odds of dying 1.68 times higher for each [1.19-2.39 and 1.15-2.46]). The odds of dying were also 2.25 times higher (1.61-3.15) in patients with oliguria. Mortality rate was lowest for cardiac output and pulmonary capillary wedge measurements of 5.1 L/min and 20 mm Hg, respectively, and increased with either higher or lower values. Patients with shock had better outcomes than patients in whom shock developed later, although for the latter subgroup, prognosis was worse in patients who had heart failure (Killip class II to III). Conclusions We devised a prognostic algorithm for patients with cardiogenic shock complicating acute myocardial infarction. In addition to demographic and easily derived physical examination features, data derived from right-heart catheterization added valuable information that increased the ability to predict outcome in this high-risk population. (Am Heart J 1999;138:21-31.)

Section snippets

Methods

The details and results of the GUSTO-I trial have been previously reported.17 In brief, 41,021 patients from 15 countries presenting within 6 hours of the onset of chest pain with typical electrocardiographic changes (>0.1 mV ST-segment elevation in ≥2 limb leads or >0.2 mV in ≥2 precordial leads) were eligible for randomization to 1 of 4 intravenous thrombolytic strategies: (1) streptokinase 1.5 million units over a 1-hour period with subcutaneous heparin; (2) streptokinase with intravenous

Results

Of the 41,021 patients enrolled in the GUSTO-I trial, there were missing data for shock status in 285 patients (0.7%). Shock occurred in 2972 patients (7.3%). Of the remaining 40,736 patients, 315 patients had shock on presentation (10.6%) and 2657 patients (89.4%) had shock develop after admission. The majority of patients who had shock develop after admission did so within 48 hours of admission.5 The demographic and clinical characteristics of the patients with cardiogenic shock and their

Discussion

In treating patients with acute myocardial infarction and cardiogenic shock, clinicians must make a number of difficult decisions concerning aggressiveness of care in the face of substantial uncertainty. Because of clear information that the mortality rate in these patients is high1, 2, 3, 4, 5, 6, 7, 24, 25 and that large amounts of resources can be expended in a futile effort, clinicians must consider withdrawal of aggressive measures in some of these patients. Alternatively, recent

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Supported by grants from Bayer (New York, NY), CIBA-Corning (Medfield, Mass), Genentech (South San Francisco, Calif), ICI Pharmaceuticals (Wilmington, Del), and Sanofi Pharmaceuticals (Paris, France).

☆☆

Reprint requests: David R. Holmes Jr, MD, Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

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